A beginners guide to PCOS (polycystic ovarian disease) & associated symptoms, causes, treatments & dietary advice
I was given my PCOS diagnosis in 2010 and it has been one of the main reasons I have struggled to get pregnant. Given that 5 – 15% of women of reproductive age have Polycystic Ovarian Syndrome (PCOS) (American Academy of Continuing Medical Education), I think it’s fair to say that I’d be in good company at a barbeque picnic.
In fact, it is one of the most common endocrine disorders in women! (Franks 2001).
The women I would be having lunch with at the PCOS picnic table would be sharing stories about having gone through several period tracking applications on their smart phone; would have burned through dozens of books about irregular periods and heavy menstrual flow; and may even have had a mini panic attack (or moment of excitement depending on their situation) at some stage because they missed a period only to find out they weren’t pregnant.
So if you are part of the crowd this article is for you.
My goal here is to provide you with a foundational knowledge of PCOS and to provide an overview of:
- What is PCOS
- Polycystic ovarian syndrome symptoms
- What it means to have polycystic ovary disease and how it affects your fertility
- Signs of PCOS, and
- PCOS treatment options
If this sounds of interest, grab a plate, here’s a steak, and would you please pass the ‘slaw?
What is PCOS?
The most common question there is – what is PCOS? Let me enlighten you… PCOS (Also referred to as PCOD – Polycystic Ovarian Disease) is a disorder of the endocrine system – the glandular factory in your body that produces the hormones used to regulate metabolism, sexual function, sleep, mood and of course, reproduction. The disorder is characterized by chronic anovulation and excessive levels of androgens – a class of hormones typically (arguably improperly) viewed as ‘male’ hormones.
How polycystic ovaries stuffs up your menstrual cycle
When a “healthy” woman has her period, her ovaries produce an egg in a tiny fluid-filled sac called a “follicle”. As the egg grows the follicle accumulates fluid until such time as the egg is mature, at which point the follicle breaks open releasing the egg. This is what ovulation is… In women with PCOS, the ovary doesn’t get the hormone recipe right for maturing the egg so ovulation doesn’t occur. Think of it as scones without yeast or baking powder. Instead the follicle remains inside the ovary forming a “cyst”, and it is the accumulation of multiple cysts over time that gives rise to the name of the disorder. Hence, polycystic ovaries… (Doctors are clearly not the most creative individuals when it comes to naming things) Anyways, I digress…
PCOS keeps bad company
People that have polycystic ovary disease are more likely than others to have cardiovascular risk factors such as:
- PCOS Insulin resistance, and impaired glucose tolerance (the warm-up acts for Type II diabetes). By the age of 40, up to 40% of all women in the US with PCOS will have developed Type II diabetes or impaired glucose tolerance (Dunaif 1995)
- “Central obesity” (a euphemism for having a fat tummy). Approximately 50% of women with PCOS are overweight or obese (Norman et al. 2004)
- Abnormally high blood pressure
- Ovary cancer
- And you-guessed-it, infertility!
If you understand the foundational concepts of functional integrative medicine you will know that just about every negative “personality trait” you may have been accused of having is likely to be a function of your physiology. When I realized this, it sure took a weight off my shoulders and I hope it does for you too! For many of you, polycystic ovary disease may be the name given to the collection of biochemical reactions that are failing to properly occur within you. Name-it-to-tame ladies! PCOS may help explain a lot of things that have been troubling you.
Causes of PCOS
Now that I’ve answered your question on what is polycystic ovarian syndrome, lets talk causes. While the association between polycystic ovarian disease and the comorbidities described above such as PCOS insulin resistance have been demonstrated by scientific research, causation does not appear to have been established. If you want to know what causes polycystic ovaries, then Mr Google will inevitably let you down as most medical professionals seem happy to accept a starting point of “we don’t know”, and I’m planning on rolling with this since we have a lot more to discuss before we start getting hung-up on things we can’t control.
Two Types of PCOS
There are a wide range of polycystic ovaries symptoms presented by women with PCOS with archetypal patients being identified as falling into one of two distinct categories:
- “Classical” PCOS and,
- “Thin Type” PCOS
To give you an example of the physiological differences possible with PCOS, you only need to compare Whitney Thore, from My Big Fat Fabulous Life (bless her), and say, Victoria Beckham from well… everyone knows who Victoria Beckham is right?
Identifying the different types of PCOS
Sudden PCOS weight gain in your late teens or early twenties is a great indicator of the onset of “Classical” PCOS. Approximately half of young women suffering from PCOS have body mass indices above the normal level, while around one in five are obese (Nair et. al. 2012). While I’m not expecting many girls under the age of 20 to be interested in this blog, the association of PCOS weight gain during your late teens might be a red-flag to some of you? While “Thin Type” PCOS sufferers generally have less severe PCOS insulin resistance and glucose intolerance than “Classical” PCOS patients, which I suppose is the more preferable end of the spectrum to be on, it also makes PCOS diagnose more difficult. My personal experience of being put on the pill at a young age as a band-aid solution to control my lack of periods is not an uncommon story I hear from many women with polycystic ovaries.
Other PCOS symptoms
Now that I have answered your question on what is polycystic ovarian syndrome symptoms, there are a few more I should mention. Besides PCOS weight gain and menstrual problems, here are a few other charming symptoms of polycystic ovary syndrome which are not much fun if you get them:
- Excessive hair growth, or hair in unwanted places like the face, chest, back, stomach, thumbs, toes
- Hair loss from the scalp; thinning of hair
- Acne and oily skin
- Dry skin (ironically)
- Depression or mood swings
- Sleep apnoea (wondering if your husband has PCOS too now? I’m convinced mine does!)
- Cold intolerance (I get this one in spades!)
Even if you are displaying most of these symptoms of polycystic ovaries, doctor will only give you a PCOS diagnosis when at least two out of three of the following criteria are met:
- An ultrasound of your ovaries reveals 10 or more follicles on a single ovary.
- Blood tests reveal high levels of androgens (testosterone).
- Your menstrual cycles are greater than 35 days apart or you have short cycles of less than 21 days
Because only two out of three criteria are required to have a PCOS diagnosis, women with regular periods can still have it and just not realize it. Just because you get your period, it doesn’t mean you are ovulating. The only way to find this out for sure is to have your luteal progesterone tested on day 21 of your cycle (Boyle et. al 2012).
Reproductive risks for women with PCOS
As well as being a major health bummer and causing infertility, polycystic ovary syndrome patients get a variety of the symptoms of polycystic ovaries with the added bonus of having increased risks of complications during and after pregnancy.
- Normal pregnancy induces a state of insulin resistance which may manifest as impaired glucose tolerance or gestational diabetes (Sivan et. al 2003).
- When women have an incidence of PCOS insulin resistance of 25-75%, they appear to be at increased risk of developing gestational diabetic complications (Legro et al 2004).
- Researches have also theorized that, as a result of Mom’s problems with insulin, the children of women with PCOS may suffer long term-health consequences due to the “fetal programming” their nutritional and hormone management systems receive while in the womb (Barker 2002).
In case this wasn’t enough to scare the sugar out of your coffee, a HIGHLY cited study conducted by a massive international team of experts found the following when they analyzed the known risks of getting pregnant with PCOS, including all the neonatal complications. Boomsma et al. (2006) found that women with PCOS demonstrated a higher risk of:
- Gestational diabetes (further supporting previous research findings
- Pregnancy-induced hypertension, and
- Pre-eclampsia (this is what killed Lady Sybil Crawley on Downton Abbey in series 3)
They also reported that the babies born to women with PCOS had a higher rate of admission to a neonatal intensive care unit and a higher perinatal mortality rate. Bugger that.
Pregnancy warnings for women getting pregnant with PCOS
Off the back of all the research being done, the recommendations from the reproductive medicine community are clear for women wanting to have babies. If you experience any of the symptoms of polycystic ovaries or have a PCOS diagnosis then:
- Take steps to avoid multiple pregnancies, as a multiple birth will exacerbate your already increased risk of pregnancy complications and adverse birth outcomes i.e. if you’re getting IVF, then consider only doing single embryo transfers.
- Adjust your lifestyle through a specialised polycystic ovarian syndrome diet to optimize your BMI.
- Get additional antenatal surveillance and early medical intervention for pre-eclampsia, hypertension, and gestational diabetes
- Consider your fetus “at risk” and ensure it is monitored throughout pregnancy and labor
Treatment for PCOS
Want to know how to treat PCOS? As there doesn’t seem to be a panacea for PCOS yet, in my mind, the “treatment” of polycystic ovaries symptoms and PCOS itself, falls into two main categories of interest to us:
- Managing the unpleasant and unhealthy PCOS symptoms, and
- Getting pregnant with PCOS and having a healthy baby.
My personal view of Functional Medicine is that is the saving grace for western medicine when it comes to chronic illness and I would strongly recommend that anyone with PCOS seek the guidance of a Functional Practitioner, regardless of how good their IVF specialist is or the other polycystic ovaries treatment they’re on. A good Functional Practitioner will blow your mind, and may take your wellness to a whole new level you didn’t think was possible. Not only relieving your polycystic ovaries symptoms but also making you an overall healthier person. And if you do achieve pregnancy success using an integrative functional approach will help insure the health of both yourself and your baby during pregnancy.
PCOS Treatment: Supplements for PCOS / Vitamins for PCOS
As well as having access to all the medications of a conventional western physician, some examples of supplements for PCOS a Functional Practitioner may offer you include:
- Vitamins B (B3, B6, B9, B12), C, D and E.
- While I’m not particularly impressed with the quality of the research, Tehrani et al. (2014) claims that taking 1 D and Calcium while on a common blood glucose regulating medication significantly improves menstrual cycle regulation, and other PCOS symptoms.
- Omega-3 supplements to help with the inflammation that goes with PCOS insulin resistance (Ouladsahebmadarek et al. 2013)
- Herbs like chasteberry, raspberry leaf, kudzu, red clover, and milk thistle, as well as traditional adaptogens such as ashwagandha, astragalus and maca to help balance hormones.
It should also be noted that preclinical and clinical studies provide evidence that six herbal medicines may have beneficial effects for women with polycystic ovarian syndrome symptoms (Arentz 2014), these being:
- Vitex agnus-castus
- Cimicifuga racemosa
- Cinnamon cassia
- Tribulus terrestris
- Glycyrrhiza spp.
- Paeonia lactiflora
Inositol for PCOS
Inositols are a group of naturally occurring carbohydrates that play an important role in many metabolic processes within our body. The two types of inositol of particular interest to women with PCOS however are known as myo-inositol (MI) and d-chiro-inositol (DCI).
MI has been proven to restore ovulation and improve egg quality in women with PCOS (Unfer et al. 2012) while a systematic review of all studies published on PCOS and DCI up until May 2010 found that DCI administration also had beneﬁcial effects on ovulation and metabolism (Galazis et al. 2011).
MI and DCI treat PCOS infertility by improving insulin resistance, androgen levels as well as many of the features of this metabolic disorder and are well worth consideration as part of any fertility treatment plan if you have PCOS.
There is a world of information available on Inositol for PCOS and I hope to bring you all a blog dedicated to this topic but in the mean-time, the most important things you need to know about these supplements are:
- Inositol may not be suitable or effective for Lean Type PCOS, especially if they do not have insulin resistance (Vitagliano et al. 2015).
- Administration of DCI alone, at high dosage, can negatively affects oocyte quality, so don’t go self-prescribing this treatment (Isabella and Raffone 2012).
- There is evidence to suggest that the most effective treatment using Inositols requires both MI and DCI in a ratio of 40:1 (Dinicola et al. 2014).
Alongside vitamins for PCOS, I’m also a big fan of traditional Chinese medicine (TCM) for PCOS natural treatment as herbs and acupuncture are a fantastic accompaniment to western medicine and especially IVF. Here is a great excerpt I’ve paraphrased from a paper by Stener-Victorin et al. (2010): “While the use of acupuncture has not been well investigated (or investigated well in many cases) by clinical trials, experimental studies show that acupuncture has substantial effects on reproductive function.
After reviewing the clinical and experimental evidence relating to the possible mechanisms of action of acupuncture on polycystic ovarian syndrome, it is clear that acupuncture modulates the nervous system, the endocrine system and the neuroendocrine system; and that acupuncture has been demonstrated to be a suitable alternative or complement to pharmacological induction of ovulation, without adverse side effects.”
See why I’m psyched on TCM and the benefits available for polycystic ovaries treatment If you’re interested in how to cure PCOS naturally, keep an eye on this space if you’re interested in TCM as this will be a topic I plan on covering often. I have had great success with it and I am passionate about sharing this fantastic option with you.
An expert in TCM for PCOS and infertility
By way of satiating your immediate need for more information on traditional Chinese medicine, please download my FREE PCOS Resource Guide, where I will refer you to some great resources on traditional chinese medicine for PCOS natural treatment and related infertility.
My own experience with TCM and PCOS
If you are like me and don’t mind hearing some anecdotal evidence I can also tell you that I have noticed a positive change in the consistency of my periods when I receive regular acupuncture. I also did acupuncture during my last two recent IVF cycles. Due to PCOS I ovulated way more eggs than is safe and was at high risk for ovarian hyperstimulation syndrome (OHSS) and I swear that acupuncture was a major reason why I did not get it. If you want to know more about this experience you can read about it here.
While I’ve only just recently learned of Ayurveda, I’m sure there are (literally) hundreds of millions of people in the world that would scoff at my western ignorance. The only reason this traditional Hindu form of medicine has come to my attention, is because there has been some great scientific research being done in this field to back-up what the Sri Lankans and Indians have known for eons.
Ayurveda or Ayurvedic medicine is a system of traditional medicine native to India, which uses a range of specialised PCOS natural treatments, including yoga, massage, acupuncture and herbal medicine, to encourage health and wellbeing. While again I’m sure I will offend just about anyone in-the-know about Ayurveda by saying so, it appears to my current state of ignorance, to have a similar tool-kit to traditional Chinese medicine. A couple of scientific reports I found, which brought my attention to Ayurveda, were in reference to the use of specific herbal medicines used to treat PCOS and relieve symptoms of PCOS:
- Siriwardene et. al (2010) claim to have gotten 30 out of 40 women diagnosed with PCOS and subfertility pregnant after 6 months of Ayurveda treatment.
- Patel et. al (2015) demonstrated that Ayurveda herbs were effective in “regularizing menstruation, achieving considerable reduction in body weight, substantial growth of follicles, and thus ovulation.” This is great news for people wondering about PCOS and weight loss
In my mind, this “alternative” form of medicine definitely seems to warrant some scientific credibility in the polycystic ovaries treatment, so I would encourage you to check it out.
Rather than give you the usual ‘blog quality’ summary of conventional medications for treating PCOS related infertility, I’ve had a crack at giving you the short-version of the published scientific state of play. So please forgive me if this is too much nerd for you ☺:
Entry Level Ovulation Drug
Any conversation about the conventional treatment of PCOS syndrome has to start with the use of ovulation inducing drugs. The oldest of these has been the first line therapy option for polycystic ovarian syndrome for 50 years. It is a simple, cheap treatment, and almost devoid of side effects (well, more than most drugs and besides making you a wee bit crazy, according to my husband) and works by indirectly resetting the cycle of events leading to ovulation i.e. it should make you ovulate. From personal experience with this, you should only try it a maximum of six times, and the efficacy decreases with each successive attempt.
I got pregnant on my second round of the entry level ovulation inducing drug, miscarried, and then did not achieve pregnancy after doing another 4 rounds. After 6 rounds my specialist at the time then suggested I move on to try the next level of ovulation induction instead (more about this below). Despite the illustrious career as the star player on the PCOS treatment team, the first line treatment doesn’t work for everyone. Although it will restore ovulation in ∼73% of patients, it will result in pregnancy in only ∼36% (Homburg 2005). The 27% of women for whom it doesn’t restore ovulation are considered to be ‘CC resistant’.
In short: ovulation induction drugs PLUS insulin sensitizers have been demonstrated to be more effective than ovulation induction drugs OR insulin sensitizers in isolation (Siebert et. al 2012). If you’re keen to do your own research, make sure you’re looking at info (or reading sources that cite studies) published after 2012 as there seems to have been a bit of a spat in the scientific community concerning the use of insulin sensitizers for PCOS. Alternatively you can let me know if you want me to further explore this topic further by leaving a comment below and I’ll do the leg work for you ☺
Selective aromatase inhibitors are promising new ovulation-inducing agents, which were developed to improve on the success of earlier drugs as well as reducing some of the drawbacks such as a high rate of multiple births. As compared with the first line ovulation inducing drug, aromatase inhibitors have been shown to be associated with higher live-birth and ovulation rates among infertile women with the polycystic ovaries (Legro et. al 2014). They have also been shown to be safe for mum and baby (Klement et. al 2015).
Before accepting your doctor’s suggestion of going onto the first line ovulation drug, check to see that he or she has read Volume 27, Number 3 of Current Opinion in Obstetrics and Gynecology (published in June 2015), where leading Canadian experts concluded that: “High-level evidence supports [aromatase inhibitors] as the first drug of choice for ovulation induction in the PCOS population. The increasing use of [aromatase inhibitors] with pregnancy follow-up provides additional reassurance for fetal safety.” To sustain my basketball analogy from above, even the greatest successes like Jordan need to retire at some point, and aromatase inhibitors may just be the Lebron James we’ve been waiting for.
Ovulation induction with hormones
If you can’t get over the line using ovulation induction drugs, insulin sensitizers, glucocorticoids and/or aromatase inhibitors your next course of action is ovulation induction with hormones or alternatively laparoscopic ovarian diathermy (see below). Having lost a pregnancy while on just the first line ovulation induction drug, and having failed to fall pregnant again during my next 4 rounds, I went to this second level of treatment for PCOS related infertility and managed to fall pregnant a second time (although I again miscarried). This method involves using injectible hormones to force your ovaries to mature a follicle and release an egg.
Similar to the first part of an IVF cycle, although with less hormones and without egg collection. The “getting pregnant” part of the process can then occur either naturally on and leading-up to the identified day of ovulation, or else can occur using artificial insemination aka IUI. According to Balen (2013): “carefully conducted and monitored ovulation induction can achieve good conception rates and multiple pregnancy rates can be minimized with strict adherence to criteria that limit the number of follicles that are permitted to ovulate.”
What this means is that a good fertility clinic will cancel your ovulation induction cycle if it looks like you’re going to ovulate more than one egg to avoid you having twins (multiple births are particularly dangerous when you have PCOS). This happened to me on my first ovulation induction cycle. For fertility clinics, ovulation induction cycles are business as usual, but for you it will mean quite a few visits to the clinic to be monitored and some significant money needing to change hands (although much cheaper than IVF).
Laparoscopic ovarian diathermy
Laparoscopic ovarian diathermy (LOD) is an alternative second line therapy for women with PCOS that is resistant to the number #1 ovulation induction drug. It is accepted as being as effective as injectible hormone ovulation induction, and is not associated with an increased risk of multiple pregnancy or ovarian hyperstimulation syndrome (the main risks with the first line ovulation induction drug) (Abu Hashim et. al 2013).
Tiny holes are then made in your ovaries which then magically somehow make getting pregnant with PCOS easy. All smart-ass-ness aside, the mechanism by which LOD actually works is not well understood, however if you want to really get your nerd on the theories are that:
- LOD reduces androgens and inhibin (a protein complex which reduces FSH production and secretion) levels resulting in an increase of FSH and recovery of ovulation (Felemban et. al 2000, Flyckt et. al 2011, Lockwood et. al 1998).
- Surgery may also provoke increased blood ﬂow to the ovary, allowing increased delivery of hormones and post-surgical intra-ovarian inﬂammatory changes that increase local growth factors (whatever that means) (Felemban et. al 2000, Seow et. al 2008, Vizer et. al 2007).
- Improved insulin sensitivity after LOD has also been suggested (Seow et. al 2007).
If you have other issues affecting your fertility in addition to PCOS; for example you also have endometriosis, tubular obstruction, or your partner’s swimmers aren’t doing too well; then the justification for IVF makes a lot more sense. Please see my blog posts on IVF for more information on this topic. You can also read about my fertility story to know more about why I ended up having to do IVF.
Regardless of the treatment you seek be it from a western physician, an eastern medicine professional, or a space-cadet from Uranus, if they have even the slightest drop of common sense in their blood they’re going to tell you what you probably don’t want to hear so I might as well say it: Making positive changes to your diet and lifestyle, like opting for a polycystic ovarian syndrome diet, is one of the most powerful things you can do to improve your fertility – especially if you have polycystic ovaries.
I know it is not as easy as popping a pill, but let me tell you from experience, all the hard work is so worth it in the end!
PCOS diet plan & foods to avoid with PCOS
If you’re looking for the perfect PCOS weight loss plan – this is my best suggestion. My Functional Practitioner has put me on what for all intents and purposes looks like a Paleo diet (with a low ratio of low GI carbohydrates), but we can just called it a PCOS diet :). If you are unfamiliar with a Paleo diet I have outlined the essentials below:
Meat: Lots of real meat, and when I say “lots”, I’m talking about 5 ounces (150 g) per meal. When I say “real” I mean the stuff that animals are made of, and not something prepared by any forming of chemical processing such as deli-meats. I know this is a controversial topic and I, myself, was vegetarian for over 10 years because I struggled with the concept, but since I have switched over to this type of PCOS diet I have seen major improvements in not only my PCOS but my energy levels as well.
Fats: Every women with PCOS needs to add lots of good fats into their PCOS diet. They have to be “good” saturated fats though and to make it simple my picks are coconut oil/butter, butter from a moo-cow, and lard. Lard is especially glorious to cook with and I thoroughly recommend you make it from scratch from grass fed, organic meat in order to avoid any chemicals or toxins.
Carbs: Just a little, and low GI. When I say “just a little” I mean around 3 ounces (85 g) per meal. When I say “low GI” I mean sweet-potato, pumpkin, black rice, and quinoa.
Sugar: Sugar is one of the top foods to avoid in your PCOS diet plan. I try to have as close to zero sugar in my diet as possible. Seriously. Sugar is bad bad bad if you have polycystic ovaries and you want to get pregnant. Well, it’s bad no matter what but when you have PCOS it is like gasoline on a fire. Be careful too, because sugar is hidden in EVERYTHING – bread, cereal, all things “low fat”, sauces, etc. And most things that are carbs, like potatoes etc break down straight into sugar too.
Vegetables: The balance of my nutrition is supposed to come from lots of green leafy vegetables. The reason I say “supposed to” is because I cheat. Sometimes I cheat a lot. It happens to me, and I’m sure it will happen to anyone that has to put up with nothing but meat and vegetables with no sweet sauces day-in-day out. Sourcing the right produce, and good cooking can make vegetables relatively interesting and delicious, but it can be a bit of effort and they’re still something I SHOULD eat, rather than what I really WANT to eat.
Inflammatory Foods: Cutting out foods you are either allergic to OR intolerant to are essential when trying to heal your PCOS through diet. For more information on this important topic you can read my blog post on how gut health and inflammation affect PCOS
Dietary advice for cheating your polycystic ovarian syndrome diet
So the thing about breaking your dietary guidelines/rules I have learned these past few years since I first went to see my Functional Practitioner is that it is going to happen from time to time so you might as well accept it and plan for it. Since you’re going to cheat, rather than just deal with it when the need arises, you can cheat smarter. I’ve also learned to mitigate the likelihood that I will want to cheat by not keeping any “junk-food” in the house, and by finding great “compliant” alternative snacks like grass fed, sugar free beef jerky and various types of nuts on hand.
How to get pregnant with PCOS exercise
There is an absolute MOUNTAIN of great research being done at the moment on PCOS exercise for PCOS weight loss success including a number of high quality papers being published in 2015 on this topic. If this is something you would like me to research, curate and deliver for you please let me know by leaving a comment at the end of this article.
So my dear friend it looks like everyone else has packed-up the picnic and headed home for the afternoon. If you’re still with me after this lengthy discourse you’re clearly either tirelessly polite, or you’re really interested in PCOS. I hope I answered your question on what is PCOS and everything in-between! In case it’s the later, please download the free PCOS Resource Guide I have put together for you, but please remember to come-back as I’m hoping to keep you updated on the latest research concerning PCOS and infertility.
I’m still trying to figure out, exactly what aspects of infertility you are really interested in so I’d love to get some feedback from you. If you liked this article and would like me to produce more content on the topic of PCOS please let me know by leaving a comment in the comments section below. Please feel free to suggest other topics you would like me to blog about too!
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