PCOS: The tests and treatments you need to know about

Polycystic ovary syndrome is thought to be all about cysts growing on ovaries. But Cate Montana has discovered that this mysterious condition has other causes and treatments, much of them to do with calming insulin levels

Excess body hair on the chest, stomach and back (hirsutism); pattern baldness or thinning hair; infertility; weight gain, especially around the belly—you would think these are the kinds of symptoms only men would have to deal with. But women struggling with a condition called polycystic ovary syndrome (PCOS) face them, too.

According to the World Health Organization, worldwide, PCOS affects an estimated 8–13 percent of all women of reproductive age. Typical additional symptoms include missed periods, irregular periods and very light flows. Some women stop ovulating altogether.

All of these contribute to one of the most crushing PCOS symptoms of all: infertility. And atypical hair patterns, acne or oily skin, skin tags on the neck or armpits, and enlarged ovaries that sometimes grow cysts (fluid-filled sacs) are other common symptoms of PCOS.

These indicators usually start after puberty in the teen years but sometimes develop later in life. As well, a woman’s symptoms may change with time. Indeed, one of the major issues with PCOS is the variability of symptoms, many of which are often indicators of other health issues and imbalances. Thanks to this frequently misleading symptomology, approximately 70 percent of women affected by PCOS remain undiagnosed.

“PCOS is missed a lot because it’s a conglomerate of symptoms,” agrees naturopathic physician and acupuncturist Dr Coleen Murphy of San Juan Capistrano, California (natmedworks.com). “Is it polycystic ovary syndrome? Or does the patient have a dysregulated microbiome on top of, say, spleen qi deficiency? It can be very misleading.”

Murphy says another major issue is that doctors tend to be specialists who are not really looking at the whole person. “One woman might worry over being obese and decide to see a weight doctor,” she says. “Another woman might go to a dermatologist and say, ‘I have acne’ or ‘My hair is thinning.’ And the doctor says, ‘Okay, take these steroids to work on your hair pattern.’

“Another woman might see another doctor and say, ‘I’m having difficulty getting pregnant,’ and the whole focus zeroes in on fertility issues. The patients aren’t necessarily talking to each other, and the doctors aren’t really looking at multiple symptoms or talking to each other. So, I think that’s one of the primary reasons why PCOS is so difficult to diagnose.”

Another issue is the name itself. “PCOS suggests that in order to have this diagnosis, a woman should also have multiple cysts on her ovaries,” says Dr Jolene Brighten, a naturopathic endocrinologist and specialist in women’s health (drbrighten.com). “This just isn’t true for the majority of cases. The name is so confusing that it leads to under-diagnosis by healthcare professionals—a much larger issue, especially when your fertility is at stake.”

Women with PCOS have other indicators beyond the common symptoms. PCOS is characterized by a predisposition to blood sugar dysregulation, impaired glucose metabolism, insulin resistance and resultant high glucose levels.

“Insulin, the hormone that regulates your blood sugar, has a large role to play in PCOS through its ability to stimulate androgen production,” says Brighten. “In the ovary, insulin and the luteinizing hormone (LH, which triggers ovulation) work together to stimulate the production of androgens (“male” hormones like testosterone).

“In addition, testosterone production is upregulated in the adrenals by insulin. This is why one of the keys to restoring fertility and your period is blood sugar control.”

Other PCOS issues that are not so commonly talked about are such things as high cholesterol levels and hypersomnia—a neurological disorder characterized by an excessive amount of sleep and/or enormous chronic sleepiness.

Then there’s hyperprolactinemia, a condition in which high prolactin levels in the blood negatively impact fertility, sexual performance and even bone health. Prolactin is a protein that helps mammals produce milk.

Anxiety and depression are more PCOS red flags. “There are so many mental health conditions with PCOS, just in the sense that you’re not feeling on top of your game all the time,” says Murphy. “Your hair falling out or your face breaking out in cystic acne might easily affect your mental health.

“In addition, there are all the hormone imbalance issues floating around, making you irritable. I often see an increase in anxiety and increased depression as well as an increase in eating disorders like bulimia and binge eating.

“A lot of women with PCOS end up with disordered eating because they just can’t lose the weight, and with all the other stuff going on, they’re constantly wondering, ‘What’s wrong with me?’ So, the mental health aspect plays a big part, too.”

What causes PCOS?

Insulin resistance and increased insulin levels are key indicators of PCOS. They directly cause a woman’s ovaries to produce more androgens than women usually have. The high androgens then suppress ovulation and trigger other symptoms, like hirsutism.

Considering the key role insulin plays, it doesn’t take a brain surgeon to realize that PCOS is directly related to a diet filled with highly refined and processed, sugar-laden, high-carbohydrate foods. As well, some modern pharmaceuticals and even artificial sweeteners trigger insulin resistance and raise insulin levels, adding to the problem.

For example, glucocorticoids are synthetic steroids that treat inflammation related to immune system disorders and allergies. Since glucocorticoid therapy for autoimmune diseases started in the 1940s, the rise in steroid-induced diabetes has been dramatic.¹ Common over-the-counter pain-relief products like ibuprofen are non-steroidal anti-inflammatory drugs (NSAIDS) that increase insulin release and can induce hypoglycemia in diabetic patients.² Studies show that the sweet taste of artificial sweeteners signals the pancreas to increase insulin levels in the blood, promoting insulin resistance.³ Even eating foods containing gluten is involved in increasing insulin resistance.⁴

The causes of increased PCOS cases thus seem obvious. And yet most allopathic doctors and traditional medical sources, such as the Mayo Clinic, say the cause of PCOS is unknown or unclear. They talk about studies showing certain genes contribute to the condition in about 70 percent of cases, but these genes are triggered by obesity and insulin resistance.

The genes are also heavily involved in the synthesis of androgens as well as steroidogenesis—the processes of converting cholesterol to biologically active steroid hormones involved in sexual differentiation, fertility, reproduction, obesity and the body’s general homeostasis.⁵

Also mentioned in clinical circles is something called endoplasmic reticulum (ER) stress. Closely associated with cardiovascular disease, ER stress is also thought to be associated with the development of PCOS.⁶ The ER is a membrane system in human cells that synthesizes and transports proteins and lipids and is vital to healthy cellular function and metabolic adaptation.

ER stress is a major contributor to metabolic disorders,⁷ such as type 2 diabetes and chronic inflammation. It also plays a key role in all the health concerns that follow metabolic dysfunction: rheumatoid arthritis, heart disease, cancer, asthma, autoimmune diseases such as celiac disease, Crohn’s disease, and pernicious anemia, as well as emotional conditions such as depression and anxiety.

How PCOS is diagnosed

PCOS is often not diagnosed because of the varying symptoms, which tend to seem unconnected and indicative of other disorders. However, according to the Androgen Excess and PCOS Society and the US National Institutes of Health, the standard criteria required for a PCOS diagnosis is threefold:

1. High levels of androgens, such as testosterone
2. Oligo/anovulation (irregular or no ovulation)
3. Cysts of predetermined size and volume as determined by transvaginal ultrasound

For a diagnosis of PCOS, two of the three characteristics must be met.⁸

For most physicians, the ultrasound, which also reveals the thickness and relative health of the endometrium—the lining of the uterus—is standard when PCOS is suspected. A pelvic exam is also recommended to determine the health of the reproductive organs. Blood tests are foundational tools for testing estrogen and androgen, cholesterol, and triglyceride levels.

However, many naturopathic physicians use a far more comprehensive approach, particularly as PCOS involves so many systems of the body (see ‘A more comprehensive diagnosis,’ below).

Standard versus natural treatment

Oral contraceptives (OCs) deliver low doses of estrogen and different types of synthetic progesterone, called progestins, to the body. By doing so, they help regulate menstrual cycles, improve hyperandrogenism and mitigate acne—which is why they have long represented the first-line allopathic approach to treating PCOS.⁹

However, studies show that OCs are linked to hypertension.¹⁰ There is a direct link between OCs and the risk of venous thromboembolism (blood clots).¹¹ Their side effects also include problems with the gallbladder and liver, such as gallstones and tumors.¹²

Metformin, a diabetes medication, is often prescribed to help regulate menstrual cycles in women with PCOS. However, side effects include hypoglycemia, lactic acidosis, muscle weakness, diarrhea, nausea and heartburn.¹³ Medications that block androgens to control acne and male-patterned hair growth are also frequently employed, but some studies show that they are not more effective than OCs for these symptoms.¹⁴

On the other hand, a healthy diet, supplements, sleep and stress management, improvements in gut health and sufficient exercise are all healthy and highly effective approaches to dealing with PCOS (see ‘Dealing with PCOS the healthy way,’ below). “I try to move people away from the medications with all the side effects,” says Murphy. “There are just so many other approaches you can use that work.”

Is PCOS curable? Most physicians, allopathic and holistic—including Murphy—say no. “I don’t know if I would use the word cure. I do think PCOS is something that you manage over the long term because it hits in so many different areas, presenting in so many different ways.

“Once you move through one part of it, you still might have another part to deal with. Like you might move through the fertility end and have a child, but then you still might need to continue treatment because you’re susceptible to insulin dysregulation and high cholesterol levels.

“With PCOS it’s more like you constantly have one short-term goal after another. ‘Where do we want our hormones next month? Where do we want the hair growth and weight loss issues to be? Are we managing our insulin?’ That sort of thing.”

The upside, say Murphy, is that all the natural aspects of managing PCOS are also the kind of things that give a woman greater health overall. “On the one hand, you might be saying, ‘PCOS is hard to deal with,’ but on the other hand, there are lifelong benefits and longevity that come with the long-term management of it.”

A more comprehensive diagnosis

Dr Brighten takes the following testing approach to diagnose PCOS.

Check hormone levels

Because PCOS results in skewed hormone levels, the following hormone tests are highly important in diagnosing it:

• Free testosterone. This level differs from total testosterone; only free testosterone exerts androgenic activity.
• Estrogen. High levels can point to PCOS.
• Progesterone. This hormone balances the effects of estrogen and androgens and tends to be low in PCOS.
• Sex hormone-binding globulin (SHBG). This hormone is often low in PCOS. It binds to testosterone and reduces its effects—free testosterone is so called because it’s not bound to SHBG.
• Luteinizing hormone (LH). TheLH test measures how much of the hormone is present in the bloodstream. High levels can indicate issues with the ovaries and pituitary gland.
• Follicle-stimulating hormone (FSH). FSH works in concert with LH to modulate sexual development and reproduction and tends to be high in PCOS.
• Dehydroepiandrosterone sulfate (DHEA-S). This sex hormone in both men and women is related to adrenal function and is often high in PCOS.

Check blood sugar levels

Because blood sugar dysregulation, insulin resistance and metabolic issues are so closely related to androgen production and PCOS, Brighten recommends the following lab tests to monitor blood sugar:

• Hemoglobin A1C. A common blood testused to diagnose type 1 and type 2 diabetes.
• Fasting glucose levels. Measures the levelsof glucose (sugar) in the blood.
• Insulin. Measures the amount of insulinin the blood to diagnose diabetes and insulin

Check gut condition

Clinical studies suggest PCOS may be related to dysbiosis of the gut microbiome,¹ so Brighten recommends looking at the gut bacteria:

• Comprehensive stool analysis. Assesses the balance of healthy versus pathogenic bacteria, yeasts, fungus and parasites in the gut.
• Lactulose breath test. A hydrogen breathtest that reveals common gastrointestinal conditions and gut dysbiosis.

Check adrenal function

The adrenal glands are often a source of androgen production, so monitoring them is valuable in treating PCOS.² Lab tests to monitor adrenal function include:

• Adrenal Stress Index. A saliva test to measure adrenal function and changes in the circadian rhythm.
• DHEA-S. See above.
• Adrenocorticotropic hormone (ACTH). Determines adrenal insufficiencies.

Check liver function

Nonalcoholic fatty liver disease (NAFLD) is commonly reported in patients with PCOS. Brighten recommends tests like these to check liver function:

• Aspartate aminotransferase (AST). Blood testfor levels of an enzyme that indicates liver damage contributing to PCOS.
• Gamma-glutamyl transferase (GGT). High levels of this enzyme in the blood indicate liver damage or disease.
• Alkaline phosphatase. High levels of this enzyme indicate liver and bone issues.
• Cholesterol test. Determines other health risks (such as cardiovascular issues).

In  addition to these tests, Dr Murphy, who is also a licensed acupuncturist, recommends the anti-Müllerian hormone test. “The cells in the ovarian follicle produce an anti-Müllerian (AMH) hormone, and AMH levels indicate ovarian reserve, or the number of eggs a woman has left,” she says. “It basically lets you know the integrity of the ovaries and how they are with eggs at that point. Elevated AMH is a strong indicator of PCOS.”

In addition, Murphy recommends thyroid tests and a comprehensive metabolic panel to look at blood sugar levels.

Dealing with PCOS the healthy way

If you’ve been diagnosed with PCOS (or if you have other hormone balance issues), optimizing the following aspects of your lifestyle can help you regain some balance.

Diet

Since insulin issues lie at the heart of hormone balance which lies at the heart of PCOS, controlling blood sugar levels through diet is a big deal. An anti-inflammatory diet, such as the Paleo or Mediterranean diet, is foundational. Dr Brighten says that most of her patients are able to control their blood sugar by adopting a whole-food diet and that going Paleo works well, too.

These are the most important things to do diet-wise:

• Regularly eat foods rich in probiotics and high fiber content.
• Increase protein intake (fish and/or nuts on a regular basis are great).
• Eliminate processed foods.
• Reduce or eliminate sugar (low- and zero-glycemic-index sweeteners such as monkfruit and allulose are okay).
• Reduce or eliminate grains from your diet.
• Eat lots of vegetables—the more, the better.
• Eat low-sugar fruits like berries, avocado, cantaloupe and citrus.
• Use organic, healthy fats like olive, coconut, avocado, flaxseed and MCT oils.
• Reduce or preferably eliminate alcohol.

Include foods high in probiotics, such as yogurt, kefir and raw cheeses from animals that are grass-fed and organic. If you’re lactose intolerant, source healthy goat or sheep milk products. Kombucha and fermented vegetables are also excellent probiotic sources.

Check out gut-healing yogurts, such as the Super Gut SIBO Yogurt from Dr William Davis that reintroduces the gut-healing bacteria Lactobaccillus reuteri and Lactobaccillus gasseri BNR17.

Exercise

Regular exercise is important. Studies show that women with PCOS improve most with vigorous aerobic exercise and resistance training, both of which improve insulin sensitivity and androgen levels.

Stress

Stress is a killer in more ways than one. It can contribute to an excess of the stress hormone cortisol, with a resulting dysregulation of other hormones in the body.

Try taking a walk in nature as often as possible. If you’re not into calming methods like meditation or somatic tracking exercises that focus and increase awareness of your body, try sitting quietly under a tree (without your phone!) for 15 minutes a day.

Sleep

Restless nights and too little sleep can wreak havoc on your hormone balance. Do your best to get seven to nine hours each night. Limiting your sugar consumption will really help with this.

Supplements

Black cohosh helps regulate menstrual cycles.

Suggested dosage: 40–128 mg extract daily for up to 12 months

Chasteberry (Vitex agnus-castus) balances hormones, improves fertility, normalizes progesterone levels and heals acne.

Suggested dosage: 160–400 mg daily

Chinese cinnamon (Cinnamomum cassia) helps with blood sugar balance, improves insulin sensitivity and glucose absorption, and fights inflammation.

Suggested dosage: 1–6 g daily

D-chiro-inositol reduces androgen levels and other symptoms of PCOS and lowers cholesterol.

Suggested dosage: 6 g once daily for six to eight weeks

Indole-3-carbinol is a good liver detoxifier that specifically helps with hormone balance.

Suggested dosage: 200–400 mg daily

Licorice contains phytoestrogens, plant-based compounds that mimic the effects of estrogen.

Suggested dosage: up to 5 g daily

Myo-inositol (vitamin B8) reduces androgens, restores ovary function and helps support metabolism. Studies show it’s as effective as Metformin for improving fasting insulin numbers and insulin resistance.

Suggested dosage: 18 g daily for four weeks

Omega-3 fish oil reduces inflammation and supports hormone production.

Suggested dosage: 50–500 mg daily

Pre- and probiotics restore gut health, balance hormones, and reduce inflammatory conditions.

Suggested dosage: 1–30 billion CFU per serving with prebiotic fiber

Resveratrol reduces inflammation, aids hormone balance, reduces androgens and improves insulin resistance.

Suggested dosage: 50–500 mg daily

B vitamins aid hormone production and support adrenal function.

Suggested dosages:

B1 (thiamin), 1.1 mg daily

B2 (riboflavin), 1.1 mg daily

B3 (niacin), 14 mg daily

B5 (pantothenic acid), 5 mg daily

B6 (pyridoxine), 1.3 mg daily

B7 (biotin), 30 mcg daily

B9 (folate), 400 mcg daily

B12 (cobalamin), 2.4 mcg daily

Vitamin D3 supports immune system, hormonal and gut health.

Suggested dosage: 400–800 IU (10–20 mcg) daily

White peony helps to balance progesterone, estrogen and androgen levels. Do not ingest when pregnant or breastfeeding.

Suggested dosage: follow label instructions

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