Polycystic Ovarian Syndrome
**Parts of this article first appeared on Lara Briden's Healthy Hormone Blog.
I invite you to think differently about polycystic ovarian syndrome.
PCOS is not one thing. It is not one disease. PCOS is a set of symptoms. The key primary symptom is a failure to ovulate regularly. Failure to ovulate is why you are deficient in estradiol and progesterone. It's why you have high testosterone, and why you develop secondary PCOS symptoms like hair loss, acne, and infertility.
You cannot treat PCOS until you first ask: "WHY — in your particular case — do you not ovulate?"
I say "in your particular case" because your reason may be different than someone else's reason. That's why there are so many different natural treatments, and that's why only some of them will work for you.
4 Types of PCOS
1) Insulin-Resistant PCOS
This is the classic type of PCOS and by far the most common. High insulin and leptin impede ovulation and stimulate the ovaries to make testosterone. Insulin resistance is caused by sugar, obesity, smoking, trans fat, and environmental toxins.
Is this you? You have been told that you are borderline diabetic, or you had an abnormal glucose tolerance test. You probably have elevated insulin, and you may also have elevated LH (luteinizing hormone). You are probably overweight, although you may be normal weight. Normal-weight insulin resistance can occur in the years following dieting or eating disorder.
Treatment ideas: You need to quit sugar and/or lose weight. Please also consider intermittent fasting, which works well to improve insulin sensitivity. Best supplements for insulin resistance are magnesium, lipoic acid, inositol, and berberine. The Pill is not a treatment for this type (or any type) of PCOS because it impairs insulin sensitivity. Improvement for Type 1 PCOS is slow and gradual over 6-9 months. Please see my Insulin Resistance post.
2) Pill-Induced PCOS or Post-Pill PCOS
The birth control Pill suppresses ovulation. For most women that are a temporary effect, and ovulation will usually resume fairly soon after the Pill is stopped. But for some women, ovulation-suppression can persist for months or even years. During that time, it is not unusual to be given the diagnosis of PCOS. Some experts deny the existence of Pill-induced PCOS, but it is very real. It is the second most common type of PCOS that I see in clinic. I have spoken to many other clinicians who are seeing the same thing. We desperately need more research into it.
Is this you? You had regular periods before starting the Pill, although you may have had acne. You probably now have elevated LH on blood test, although you may have normal LH and high-normal prolactin.
Treatment ideas: If your LH is elevated, the best herbal treatment is Peony & Licorice combination. I know Peony & Licorice is difficult to access outside of Australia, but hopefully, that will change in near future. If your prolactin is high-normal, then the best herbal treatment is Vitex (also called chaste tree or chaste berry). Do not use Vitex if your LH is elevated. Vitex stimulates LH so it will make things worse. Indeed, many of my PCOS patients report feeling worse on Vitex.
Both Peony and Vitex work on your pituitary-ovarian axis and they are powerful herbs. I recommend you do not use them too soon or for too long. Do not take them if you are a teenager, or if you have just come off the Pill. Give yourself at least 3-4 months off the Pill. Peony and Vitex should not be used for more than 10 months in a row. They should not need to be used that way. If they are the right herbs, they will work fairly quickly (within 3-4 months). And then, your periods should stay regular after you stop the herbs. You should not take licorice if you have high blood pressure. Please seek professional advice.
3) Inflammatory PCOS
Inflammation—or chronic immune activation—results from by stress, environmental toxins, intestinal permeability and inflammatory foods like gluten or A1 casein. Inflammation is a problem for PCOS because it impedes ovulation, disrupts hormone receptors, and stimulates adrenal androgens such DHEA and androstenedione.
Is this you? You have other symptoms of immune dysfunction such as recurring infections, headaches, joint pain or skin conditions. Your blood test shows inflammatory biomarkers such as vitamin D deficiency, abnormal blood count, elevated C-RP, thyroid antibodies, or gluten antibodies. You may have elevated DHEA or androstenedione, and a positive urine test for intestinal permeability.
Treatment ideas: Reduce stress and exposure to environmental toxins like pesticides and plastics. Eliminate inflammatory foods such as wheat, dairy, and sugar. Treat intestinal permeability with zinc, berberine, and probiotics. Supplement magnesium because it is anti-inflammatory and normalises adrenal hormones (HPA axis). Improvement is slow and gradual over 6-9 months.
4) Hidden-Cause PCOS
This is the ‘simpler-than-you-think’ type of PCOS. Fairly often (at least once per week) I encounter a PCOS patient who does not meet any of the criteria for the first 3 types of PCOS. These are my favourite cases because it usually means that there is one simple thing that is blocking ovulation. Once that single thing is addressed, this type of PCOS resolves very quickly, usually within 3-4 months. Common hidden causes of PCOS include:
– Soy, because it is anti-estrogen and can block ovulation in some women.
– Thyroid disease, because your ovaries need T3 thyroid hormone.
– Vegetarian diet, because it causes zinc deficiency, and your ovaries need zinc.
– Iodine deficiency, because your ovaries need iodine. Please be careful with iodine supplementation as too much can harm your thyroid. Maximum dose 0.5 mg.
– Artificial sweeteners, because they impair insulin and leptin signaling.
– Too little starch in your diet, because your hormonal system needs Gentle Carbs.
Is this you? You do not exactly fit the criteria for the first 3 types of PCOS. You have tried a number of natural PCOS treatments and nothing seems to work. Look deeper.
For more detail about the types of PCOS, please Lara's book Period Repair Manual. It includes a visual flow-chart of the 4 PCOS types.
Don't Be Too Quick to Accept a Diagnosis
Ultrasound is NOT enough to diagnose PCOS. 25% of perfectly normal women display polycystic ovaries at one time or other (1). A subsequent ultrasound will show it to be normal again. True PCOS involves hormone irregularities that must be picked up with blood test.
Do you actually have PCOS? Which Type? Take our PCOS Quiz to find out. You can also consult with one of our qualified Naturopaths.
Many cases of PCOS are temporary. More specifically, many cases of so-called PCOS that we see in our clinic can more accurately be described as post-Pill syndrome. Your doctor will not tell you this, but it is a medically recognised fact that it can take up to 2 years for normal ovulation to resume after stopping the Pill. (2)
Blood tests necessary to diagnose PCOS are:
- fasting blood glucose
- fasting insulin
- fasting leptin
- thyroid function
- vitamin D (vitamin D deficiency affects hormone balance)
- urinary iodine
Our Naturopaths can order these blood tests for you.
Polycystic Ovaries Are NOT the Same as Ovarian Cysts
The cysts that you see on ultrasound are not abnormal growths. A normal ovary produces fluid-filled follicles that contain the eggs. These follicles are essentially 'cysts'. Normal cysts (that the ovary is supposed to have) form and are reabsorbed every month, in every woman. Follicles of different number and different size will be visible in every normal ovary. They will look different on every ultrasound.
It is only when the ovarian follicles do not form properly, that the concept of abnormal cysts has some meaning. Follicles can be too large (the type of 'ovarian cyst' that can cause pain or rupture), or too small (as seen is polycystic ovaries). Polycystic ovaries or 'multiple cyst ovaries' means that the ovaries - at the time of viewing - have too many small, underdeveloped follicles. This occurs because ovulation has not occurred properly in that month. (It could be completely different in a month or two). Failure to ovulate properly can be due to a number of causes, but in true PCOS, it is due to a problem with testosterone, and often, a problem with insulin.
Let me repeat. The polycystic appearance may mean nothing - may be normal. Or the ovaries may look that way because something is preventing ovulation from progressing normally. That "something" is either insulin (in classic, Type 1 PCOS), or something else (Type 2 PCOS). (see below)
The ovaries themselves are not the cause of weight gain. In Type 1 PCOS, insulin resistance is the cause of the weight gain. Insulin resistance is also the cause of the polycystic appearance of the ovaries, the lack of proper ovulation and the lack of periods.
Know when it's time to let go of your PCOS Diagnosis. In most cases, PCOS is not a permanent condition. With the right diagnosis and the right treatment, PCOS can become a thing of the past.
Hormonal Birth Control is Not a Treatment for PCOS
The Pill is not a solution for PCOS. It does absolutely nothing to improve the underlying insulin resistance, and can actually worsen it (3). In 2003, the Journal of Clinical Endocrinology & Metabolism published an article called 'A Modern Medical Quandary: Polycystic Ovary Syndrome, Insulin Resistance, and Oral Contraceptive Pills'.(10) The Pill has been standard treatment for PCOS, and yet, perversely, it appears to worsen the metabolic problem that is at the root of the condition. The authors say:
'...what has been lacking is a critical examination of whether oral contraceptives might...exert adverse metabolic effects with long-term consequences..'.
The Pill may have made further contributions to the epidemic of PCOS. The Pill is known to cause permanent hormone changes, even once it is stopped.(2) In particular, the Pill causes chronically elevated LH, which is a major feature of many cases of PCOS. It can take up to 2 years to get ovulation going after stopping the Pill. (Some women are lucky to have periods start up quickly, but that is not the case for everyone.)
The monthly bleed induced by the Pill is a chemically-induced event. It is not a period. It is no indication of what your own hormones are doing. In fact, while on the Pill, your own hormones are completely suppressed. The Pill is chemical castration.
Interesting Facts about PCOS
PCOS is linked to thyroid disease
A recent German study has found that PCOS sufferers have an increased risk for autoimmune thyroid disease. (4)
The researchers believe that the progesterone deficiency associated with PCOS makes women more susceptible to the autoimmune condition. It may also be that women with thyroid conditions are more like to develop PCOS. Healthy thyroid function is necessary for healthy ovulation.
Autoimmune thyroid disease also called Hashimoto's, is common. Read more about it here.
PCOS may improve with age:
According to Swedish researcher Miriam Hudecova:
"As [PCOS patients] get older, their chance of getting pregnant may actually be higher,"
Her research shows that by the age of 35, women with PCOS have had as many successful pregnancies as women without PCOS, even without the assistance of fertility treatment. (5)
The number of follicles in the ovaries gradually reduce as women age. Normally, this is a bad thing, but it appears to be a good thing for PCOS sufferers. Other studies have shown something similar in that the periods of PCOS patients become more regular over time.
Author: Lara Briden BSc, ND. Sensible-Alternative Naturopathic Clinic.
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(1) Polson DW et al. Lancet. Polycystic ovaries--a common finding in normal women.1988 Apr 16;1(8590):870-2.
(2) Gnoth, C et al. Cycle characteristics after discontinuation of oral contraceptives. Gynecol Endocrinol 2002:16(4): 307-17.
(3) Nader, S et al. The effect of desogestrel-containing oral contraceptives on the glucose tolerance and leptin concentration in hyperandrogenic women' J Clin Endocrinol Metab 1997 82: 3074-7
(4) Janssen OE. High prevalence of autoimmune thyroiditis in patients with polycystic ovary syndrome. Eur J Endocrin 150(3): 363-369
(5) Hudecova, M et al. Long-term follow-up of patients with polycystic ovary syndrome: reproductive outcome and ovarian reserve. Human Reproduction, doi:10.1093/humrep/den482