PCOS Crash Course
Polycystic Ovarian Syndrome, or PCOS is thought to affect around 5-15% of women, with majority of women remaining undiagnosed until later in life, usually when fertility issues arise.
PCOS is a set of symptoms, rather than a disease, and is marked by elevated androgen levels and impaired ovulation. Hirsutism (hair growth), acne and infertility are common presentations, with conditions such as metabolic syndrome, obesity (though not always), high cholesterol and high blood pressure also concerning factors.
The diagnosis of PCOS is via the Rotterdam Criteria, where a positive of 2 out of 3 of the following signs indicate the presence of the syndrome:
1. Clinical and/or biochemical evidence of hyperandrogenism
2. Evidence of oligo-anovulation OR
3. Ultrasonographic evidence of a polycystic ovary
What does this all mean though?
You must have physical signs of androgen excess and/or pathology results indicating so; You are not ovulating or ovulation is occurring infrequently; and you may OR may not have evidence of polycystic ovaries seen on ultrasound (you do not need to have “polycystic ovaries” though and polycystic ovaries do not always indicate PCOS). So really, PCOS may actually have nothing to do with cysts on the ovaries!
What are the common signs and symptoms?
Enlarged Ovaries and multiple cysts (not always!)
Irregular menstrual cycles
Hirsutism (facial hair)
Central Obesity
Infertility (as a result of anovulation)
Elevated serum androgens such as testosterone, androstenedione, DHEA
Androgenic Alopecia (male pattern baldness) yep- you can grow hair on your face and not on your head.. WTF!
Acne/ Oily skin
Prolonged PMS like symptoms
Chronic Pelvic Pain (this can be due to many other factors and should be checked out!)
Sleep Apnoea
Blood sugar dysregulation
Hypothyroidism
Unfortunately, the standard treatment for PCOS is the oral contraceptive pill (OCP). It is important to note, that the OCP does not “treat” PCOS, rather masks the symptoms. The OCP shuts off the HPO Axis, that is, the hormonal chat between the brain and the ovaries, resulting in ovulation suppression. Your bleed on the OCP is not a period, rather a drug withdrawal bleed, so don’t be fooled… the OCP hasn’t brought back your period, it hasn’t lead to ovulation (quite the opposite) and it hasn’t fixed the driving factors.
So how do we help to address PCOS more holistically?
You need to know what YOUR driver is. Everyone is a bit different!
First of all, if androgen excess has been found, you need to rule out other causes. Conditions such as congenital adrenal hyperplasia; high prolactin; as well as hormonal birth control with a high androgen index can all lead to androgen excess. If you lost your period, you need to rule out hypothalamic amenorrhoea (HA) as a potential cause. A PCOS diagnosis often gets slapped on women who actually have HA so it is important to differentiate (that’s a whole other blog post).
Once these things are ruled out, we can get to the nitty gritty.
So we know we have high androgens, now we need to find out why. It can be a few things, all of which are treated a little differently. These classifications help natural health practitioners to treat PCOS more holistically and we can thank the amazing Lara Briden for all her work in the area.
Insulin Resistant PCOS (the most common)
Elevated Insulin supresses ovulation, and tells the ovaries to make testosterone, it’s a classic catch 22. It is important to test fasting insulin AND fasting blood glucose/ HbA1c, as fasting glucose alone does not indicate insulin sensitivity. For this type, we want to limit refined sugars, high dose fructose, and trans-fats and get off the smokes. A high fibre, plant rich diet is key, and gentle intermittent fasting can also assist. There are of course many nutritional and herbal supportive measures, but Myo-Inositol is always a part of it. We usually see elevated LH + elevated fasting insulin + elevated androgens.
Post Pill PCOS
So you’ve stopped the pill, you had your withdrawal bleed, and now 4 months later, nothing… if you had a regular period before going on the OCP then you may have Post Pill PCOS. If your period was irregular and your cycles long before going on the OCP, then you may have had undiagnosed PCOS of another type (remember, the OCP does NOT fix PCOS). Coming off certain OCPs (containing drospirenone or cyproterone) can lead to a bit of a bounce back surge in androgens. This surge is usually temporary but can last a few months. You are likely to have elevated androgens; high-normal LH; high- normal prolactin in your blood tests. Treatment wise, we will use some anti-androgen supplements which will highly likely involve zinc among other things. Herbals depend on pathology results and the patients clinical picture.
Inflammatory PCOS
Inflammation supresses ovulation via the stimulation of testosterone (that catch 22 situation!), but where does it come from? Food sensitivities to gluten or casein (dairy); chronic immune issues and autoimmunity; gut issues; environmental toxin exposures; histamine intolerance, the list goes on. What we see here is an elevation in androgens + something that indicates an inflammatory response. That could be elevated blood inflammatory markers (like ESR or CRP); abnormal blood counts; autoimmune antibodies; gut testing abnormalities and more. Inflammation is a key process in all types of PCOS, but if you are not insulin resistant and not in a post pill phase, then this may be the significant driving factor. Generally speaking, a clean up of the diet and environment is key, as well as addressing what the specific cause of inflammation is. Hint, you can’t just take some Turmeric 😉
Adrenal PCOS
This was me! It still is if I am not looking after myself. I will tell that story another time. This one is a little easier to pick out. If your elevated androgen is ONLY DHEA (not testosterone or androstenedione) then it is probably adrenal PCOS. Stress is a big driver for this one, and inflammation is often also present.
So, there you have it. A quick PCOS 101. Your take home messages:
PCOS treatment should be individualised to your personal driving factors
The oral contraceptive pill does NOT treat PCOS, or any other menstrual disorder for that matter