What is PCOS?
PCOS is a relatively common condition related to hormonal problems within women of childbearing age (between 15 and 44) and is said to affect anywhere between 2 and 27% of women in this age group. Many women also go undiagnosed with one study in 2010 finding that 68-69% of women they looked at with PCOS had not been diagnosed with the condition.
PCOS affects women’s ovaries which are the reproductive organs responsible for producing the hormones oestrogen and progesterone which are related to a woman’s menstrual cycle and its regulation. The ovaries also produce hormones known as androgens, which are usually thought of as the male hormones, although female bodies do produce a small amount too.
Women with PCOS often have issues with the metabolism of androgens and oestrogen and struggle to control the production of the androgens. Those diagnosed with PCOS often have irregular menstrual cycles which can be either prolonged or infrequent and may also have a excess of the male hormone levels (androgens) but we’ll look at the symptoms later.
In a regular cycle the hormones FSH (follicle stimulating hormone) and LH (luteinising hormone) are produced in the pituitary gland and control ovulation. FSH stimulates the ovary to produce a follicle (as the name suggests) and LH levels tell the ovaries when to release a mature egg. The follicle is a sac which contains an egg which then matures and develops to become the final egg that is released.
In PCOS, the ovaries contain many sacs or cysts which are the follicles and are filled with fluid which grow within the ovaries themselves and contain the eggs, but in the case of PCOS the eggs never develop to become mature and cause ovulation. The word Polycystic means ‘many cysts’.
PCOS is known as a syndrome, which means it is a group of symptoms and the NHS describes it has having 3 key features:
- Irregular periods – either prolonged or infrequent menstrual cycles due to the ovaries not releasing the eggs (ovulation) regularly
- Polycystic ovaries – the ovaries contain many of the fluid filled sacs (follicles) which do not mature and the ovaries themselves become enlarged
- Excess androgen – higher levels of the ‘male’ hormones which can cause certain symptoms such as excess facial or body hair
A woman will often be diagnosed with Polycystic ovaries (not necessarily PCOS) if she has more than 12 or more follicles (cysts) on at least one ovary.
More than half of all women with the syndrome have no symptoms of PCOS.
Causes of PCOS
The exact causes of PCOS aren’t really known but can often result from an abnormal functioning of the hypothalamic-pituitary-ovarian (HPO) axis which controls the messaging and release of hormones.
Although exact causes aren’t always known, there are a number of possible causes or contributors leading to PCOS:
High insulin: Elevated insulin levels can lead to insulin resistance, which through complex pathways within the body, can lead to an increase in the levels of ovarian and adrenal androgens (the male hormones). It is also suspected that increased insulin levels can reduce the amount of a protein called SHBG (sex hormone binding globulin) produced by the liver. This protein binds itself to the sex hormones and carries them throughout your blood. SHBG also controls the amount of testosterone your body can use and too much testosterone (an androgen) is one of the key features of PCOS.
Ovarian dysfunction: If the hormone levels aren’t well balanced and levels of ovarian androgens are too high and oestrogen levels are too low these can lead to and promote the development of the immature follicles that accumulate in the ovaries and as result cause an imbalance in the levels of FSH (follicle stimulating hormone) and LH (luteinising hormone) which prevents the maturation of the follicles and ultimately ovulation.
Weight gain: When there is an increase in the levels of fatty tissue, and often the type found round your middle, this can affect the sex hormone levels. Excess weight can also cause the body to produce more insulin which as mentioned above is also linked to PCOS.
Genetic predisposition: Around 40% of women with a family history of PCOS will have the condition although not of these people will show any symptoms.
Adrenal dysfunction: where the adrenals production of androgens causes elevated levels of oestrone, one of the 3 main types oestrogens produces by the ovaries and high levels are associated with PCOS.
Dysfunction of the hypothalamic-pituitary axis: this can lead to a dysregulation in the levels of certain hormones released and most specifically LH and FSH.
Symptoms of PCOS
As mentioned previously, some women don’t have any symptoms of PCOS at all, however, many do, and these are some of the most common symptoms associated with PCOS:
Irregular periods, or no periods at all: Some women with PCOS don’t get any periods at all and many have fewer than 8 a year. It is the lack of ovulation that stops the uterus from shedding it’s lining as usual each month.
Difficulty getting pregnant: The lack of ovulation makes it harder for women to conceive
Heavy bleeding: As the uterine lining does not always shed regularly it can allow it to build up for a longer period of time leading to heavier than usual periods
Excessive hair growth (also known as hirsutism): Women with PCOS often experience excess hair growth on the face, chest, back and/or buttocks. IT is estimated more than 70% of with PCOS have this as a symptom
Acne or oily skin: The excess androgen (male hormones) as well as causing the excess hair growth can also cause skin to be oilier than normal leading to breakouts and acne on the face, chest and upper back
Weight gain: Research has shown that up to 80% of women with PCOS are overweight or obese
Thinning of the hair and hair loss (from the head): The excess male hormones can also lead to hair loss and thinning on the head often resembling male pattern baldness
Darkening of the skin: Dark patches of skin can sometimes be found in body creases such as around the neck, groin and under the breasts and is linked to insulin resistance
Headaches: The changes in hormone levels can sometimes trigger headaches in women with PCOS
How is PCOS diagnosed?
GP’s will talk to you about your symptoms and work to rule out any other possible causes. There are also a number of tests that the GP will look to run:
Hormone tests: this will help to understand what is happening with your hormones and whether there are any other hormone related conditions that could be causing your symptoms.
You can also get hormone tests done at private laboratories through consulting with a qualified nutritional therapist. These often go into a lot more detail than the ones run by your GP but they do cost money. It is always best to see what your GP can do for you first.
Ultrasound scan: Your GP may also arrange for an ultrasound scan to be run which will show up whether or not you have polycystic ovaries (high numbers of follicles in your ovaries).
Blood tests: as well as blood tests being another way to look at your hormone levels they can also look at your blood sugar levels checking for diabetes and cholesterol which are both often associated with PCOS and can evaluate your risk for developing diabetes or heart disease.
How else can PCOS affect you and your body?
The different hormone levels, and in particular, the higher than usual androgen levels, can lead to other impacts on your health including your fertility.
Some of the other areas of your health that can be affected by PCOS and the associated hormone changes are:
Infertility and Pregnancy: As PCOS changes the menstrual cycle and its regularity it does make it harder for people to get pregnant with an estimated 70-80% of women with PCOS having fertility issues. The condition can also lead to a higher level of risk during pregnancy such as miscarriage, premature delivery, high blood pressure and gestational diabetes.
Sleep apnoea: Women with PCOS are more likely to suffer with sleep apnoea, especially if they are also obese. This is where breathing is paused briefly during the night which can interrupt sleep.
Metabolic Syndrome: This is a collection of symptoms including high blood pressure, high blood sugar levels, low HDL cholesterol (‘good’ cholesterol) and high LDL cholesterol (‘bad’ cholesterol). Together these things can increase the risk of getting conditions such as heart disease, diabetes or a stroke.
Depression: The hormonal changes within the body along the presenting symptoms such as infertility and excess hair growth can lead to women with PCOS suffering from anxiety or depression.
Now a lot of this can all sound quite bleak but just because you have PCOS does not mean that any of things have to happen to you, and there are many things you can do yourself to improve your condition and overall health by making some dietary and lifestyle changes.
Medical treatments for PCOS
The NHS has a lot of information on the types of treatment available as well as the different medications used to try and support patients with PCOS and address the individual symptoms. The GP will assess each individual patient and ascertain the best treatment plan. Below are some of the most common treatments given but for more information visit the NHS website:
- Metformin – this is used to manage insulin resistance and lower blood sugar levels to help stimulate ovulation.
- Cyproterone acetate – Used to treat acne and excess hair growth (hirsutism)
- Oral contraceptive pill – also used to treat acne and excess hair growth whilst also trying to encourage more regular periods
- Spironolactone – also used to treat hirsutism and acne
- Progesterone – this is used to trigger withdrawal bleeding and encourage regular periods
- Clomiphene – this is for improving ovulation and fertility for those wanting to conceive as it encourages the monthly release of an egg from the ovaries.
Is this the only option?
These medications all serve a purpose, however, as PCOS is a lifelong condition we need to be looking at ways of managing it through getting to the root cause and correcting that. This can include making changes to our diet and lifestyle to help correct underlying hormonal imbalances, and correcting blood sugar imbalances and insulin resistance.
Even with the conventional treatment from the GP you can still work on the underlying cause at the same time and that is often what I work on with my clients.
Dietary and Lifestyle recommendations for PCOS
By addressing some of the underlying causes the dietary and lifestyle changes look to deliver against some of the following health goals:
- Weight loss and especially decreasing central obesity (fat around the middle) and improving muscle composition
- Decreasing insulin resistance to help improve hormone balance
- Support the liver and gut to promote clearance of excess hormones
- Regulating stress levels and the impact on cortisol and hormones
By looking to these goals and working on them through diet and lifestyle you are looking to improve the overall hormonal balance and regulate ovulation.
You want to be aiming for at least 1 hour of exercise 4 times a week, or 20 minutes daily. If you are new to exercise though, try by starting with 30 minutes of moderate intensity exercise at least 3 days a week. Combining exercise with dietary changes is the most beneficial plan as this is shown to be more effective for weight loss than either diet or exercise alone. This will help lose weight when needed and also improve insulin levels and ovulation, whilst lowering the risk for diabetes and heart disease.
As mentioned above a combination of diet and exercise is the best way to lose weight. Research has shown that a drop of just 5-10% of your body weight can help improve symptoms of PCOS and regulate your menstrual cycle. Weight loss can also lower insulin, improve cholesterol and reduce the risk of heart disease and diabetes.
Implementing some or all of the below can also help support women with PCOS:
- Increase fibre intake within the diet – This can be done by eating more whole food and whole grain products (e.g. brown rice, wholewheat bread and pasta), increasing the amount of vegetables you eat and have them at every meal, swapping cereal at breakfast for porridge with fruit and added nuts and seeds
- Reduce the amount of trans and saturated fats eaten – Some fats known as unsaturated are good fats to have in your diet and come from things like nuts, seeds, avocados and olive oil but saturated and trans fats are ones you want to cut out of your diet where possible. Trans fats are a form of processed cooking oil and are known to be one of the most dangerous food additives and they are found in many fast foods and takeaways as well as doughnuts. Saturated fats are found in chocolate, cakes, biscuits, pastries, pies, processed and fatty meats among others.
- Decrease sugar and refined foods – as well as reducing the amounts of sugar consumed through table sugar, chocolate and sweets etc. it is also worth reducing the level of refined foods which break down into sugar easily and quickly in the body and are food items such as white breads, pasta and rice.
- Increase protein intake – Women with PCOS often report higher levels of food cravings and increasing protein can often reduce or remove these cravings and help keep you feeling fuller for longer. Good sources of protein include; eggs, lean meat, yoghurt (plain), fish, tofu, tempeh, seitan, nuts and seeds as well as beans and pulses.
- Consider a low GI/GL diet – Glycaemic Index or Glycaemic Load is a way of measuring the carbohydrate and sugar content of a food and the effect it will have on your blood sugar levels. A low GI or GL diet generally means you get most of your carbohydrates from fruits, vegetables, and wholegrains.
It’s quite hard to make general advice as everyone of us is unique and every woman with PCOS will have different symptoms, priorities, and goals. Generally, the best route would be to try and combine weight loss with a healthy diet consisting of the above suggestions including low GI/GL foods. Working with a qualifies nutritionist or nutritional therapist will enable you to find the right dietary and lifestyle changes specifically for you.
Supplements for PCOS
You should always seek the support of a qualified practitioner such as a Nutritional Therapist before deciding on a regime of supplements. You should also always consult your doctor on what you are taking, especially if you are on any medication.
There has been various research done on some of the supplements available to support PCOS and some of the ones I’ve used in clinic are as follows:
- Myo-Inositol – this has been shown to improve all areas of PCOS including insulin sensitivity, inducing ovulation, metabolic health and hormonal balance.
- Vitamin D – Women with PCOS often have insufficient vitamin D levels and this is thought to increase insulin resistance as well as help with the maturation and development of the egg
- Omega 3 (EPA & DHA) – this has been linked to increased fertility and lowering male hormone levels (androgens). You can also get Omega 3 from oily fish such as salmon, mackerel, anchovy, sardine and herring). Research also shows it can reduce risks of heart disease.
- Chromium (Picolinate) – This has been found to improve glucose tolerance and insulin resistance.
If you are someone with PCOS, whether you have some or all of the symptoms and would like some more personalised help then get in touch with Helen at Helen Jane Nutrition. She has supported many clients take back control of their condition, lose weight and improve the regularity of their menstrual cycles. Everyone is unique so get in touch with Helen for your own personalised plan to get the results you are looking for.