Polycystic Ovary Syndrome

PCOS affects between 5-10% of menstruating people

What is PCOS?

PCOS is a body wide endocrine and metabolic condition.

The key defining feature of PCOS is ovulatory dysfunction and the overproduction of testosterone and androstenedione by the ovaries.

Regularly disrupted and delayed ovulation causes downstream effects:

  1. Progesterone deficiency

  2. Androgen excess

  3. Androgenic symptoms

  4. Infertility

  5. Later in life risks: bones,
    cardiovascular, brain health

Why PCOS is a Misnomer

The ovaries are healthy with PCOS, and they want to release eggs, but can’t in the environment of too much testosterone

It’s not really about “cysts” on your ovaries. “Cysts” are simply the presence of multiple normal undeveloped follicles (egg sacs) on the ovaries

PCOS is a metabolic and endocrine disorder (which is missing from the name).

Causes and Correlations

The cause of PCOS is not conclusive. Researchers think it’s a mixture of genetics, epigenetics, and environment. Genome wide studies help us understand how PCOS is inherited and why PCOS symptoms vary widely between people.

  • An exposure to excess androgens, insulin, or other endocrine disrupting chemicals while in the womb.

  • Signs of this exposure may not become apparent until puberty reveals hormone imbalances like androgen excess.

  • Excess androgens cause insulin resistance, delayed ovulation, and low progesterone.

Symptoms and Diagnosis

Symptoms

  1. Irregular menstruation and cycles longer than 35 days

  2. Signs of high testosterone (hirsutism: beard stubble, coarse hair, rough stubble), alopecia, severe / cystic acne, across chest arms back or jaw, blood tests)

  3. Multiple follicles (cysts) seen on the ovary

Whole body symptoms include

  • Mood disorders

  • Inflammation

  • Gut Issues

  • Liver Issues

Diagnosis

  • Must have 2 of 3 criteria present

    • Ovarian dysfunction (lack/less frequent ovulation)

    • High levels of androgens DHEA & testosterone (free & total) or symptoms of androgen excess because testosterone blood tests are unreliable

    • And/or polycystic ovaries on an ultrasound

  • Ultrasound cannot be used as the sole criteria for diagnosis.

  • The Androgen Excess Society guidelines suggest PCOS not be diagnosed in teens unless all 3 of the criteria are met because many aspects of puberty mimic PCOS and subside by age 20

Misdiagnosis and Similar Conditions

Rule out these conditions when exploring a PCOS diagnosis

    • Triggered by things that affect the adrenal glands, such as stress, which affect the hypothalamic-pituitary-adrenal axis(HPA) 

    • Androgen excess is coming from your adrenal glands above the kidneys, and not your ovaries like classic PCOS.

    • It is more common in lean people

    • Dehydroepiandrosterone sulfate (DHEA-S) only comes from the adrenals, so testing for high levels of DHEA-S on a blood test is vital to ruling out AAE PCOS.

    • If you have high prolactin or high adrenal androgens (DHEA-S) but normal testosterone and androstenedione, then you specifically have adrenal androgen excess.

    • Adrenal-androgen PCOS is a different condition from ovarian-androgen PCOS because it’s not rooted in insulin resistance or underlying conditions that impair ovulation.

    • HA has many similar symptoms to PCOS including loss of ovulation, high anti-mullerian hormone (AMH) test, and the presence of polycystic ovaries on an ultrasound.

    • If you were diagnosed with PCOS from only ultrasound & AMH, rethink your diagnosis. 

    • HA is caused by under eating carbs or under eating in general

    • Luteinizing Hormone (LH) tests (ovulation predictor kits) taken on the second day of your menstrual cycle or any day if you aren’t cycling will help you rule this out. 

    • If luteinizing hormone is high, it points to PCOS. If LH is low, points to Hypothalamic Amenorrhea.

    • Complicating this picture, is the fact that you can swing from PCOS to HA if you are not treating the condition properly.

    • Group of genetic disorders affecting the adrenal glands and can be misdiagnosed as PCOS (~9% of the time). 

    • A person with CAH lacks one of the enzymes the adrenal glands use to produce hormones that help regulate metabolism, the immune system, blood pressure and other essential functions. 

    • Usually diagnosed in infancy or young adulthood but milder cases can also be diagnosed in adults.

    • Work with your healthcare practitioner to get tested for CAH if your symptoms sound similar. (ACTH, 17OHP).

PCOS at the Root

The condition triggers androgens which disrupts our cycling hormones (estrogen + progesterone).

People with PCOS typically have low progesterone at the same time that they have high androgens from the lack of robust and frequent ovulation cycling.

Low progesterone causes an imbalance of estrogen and progesterone, leading to high estrogen & poor estrogen metabolism.

Dysregulated feedback loops keep the body from cycling normally, causing body wide metabolic dysfunction and impairing healthy endocrine signaling.

  • PCOS has many long-term health risks such as cardiovascular disease, fatty liver disease, and type 2 diabetes and as such is a potentially serious condition that lasts beyond the reproductive years.

  • It can start in childhood & continues past menopause - PCOS is a whole body condition and not a reproductive specific disorder

  • Genetic predispositions exist, however these genes can get activated by lifestyle & environment. 

  • It responds best to deep nutrition, herbalism, and lifestyle changes that address the root issues of inflammation, insulin resistance, and metabolic dysfunction.

How PCOS Disrupts the Ovarian and Uterine Cycle

  • Follicles go through a slow state of growth known as folliculogenesis for many months before the egg is ready to be ovulated. 

  • In PCOS, this process can become stalled because of high testosterone and insulin in the ovary. 

  • The outer layer of the follicle known as the theca, which produces testosterone, thickens, and the follicles stall in their development process and accumulate in the ovaries rather than going through ovulation.

  • PCOS “cysts” are actually just ovarian follicles that are in a state of partial development.


  • The uterus is stalled in its proliferative phase, where the uterine lining builds anew after the last menstruation in preparation for the next ovulation

  • As long as estrogen levels remain high (and it is because it is not balanced with regular progesterone), the uterus will continue to build thicker uterine lining

  • This is why PCOS can sometimes be associated with heavy bleeding, endometrial hyperplasia, and the passing of decidual casts

  • PCOS does not *inherently* cause pain but some of its downstream effects on the uterine cycle can cause painful menses, related to high, fluctuating estrogen or poor estrogen metabolism

PCOS Subtypes

    • When you’re resistant to insulin, it means you’re resistant to very small amounts. So you need more than normal as put out by your pancreas. 

    • Higher insulin levels means insulin hangs around longer in the body & insulin binds to the ovaries, telling them to make more testosterone.

    • Ovaries, which wants to put out the small bit of testosterone you need, are suddenly ramping up production

    • This results in secondary effects of testosterone: chinstrap acne, hirsutism hair growth, irregular or no cycles

    • With PCOS, your body stores more fat around the organs, insulin resistance feeds testosterone & vice versa.

    • Address the root cause of insulin resistance

    • The immune system is important for natural body processes & how we fight infection

    • But chronic inflammation disrupts ovulation, hormone receptors, and increases androgens

    • Fat cells that are enlarged spill free fatty acids which causes inflammation in the bloodstream

    • Fat necrosis occurs, where fat cells die & the immune system has to clean them up 

    • So you may have low grade inflammation from fatty tissue dysfunction as well as insulin resistance

    • This inflammation further exacerbates insulin resistance

    • Food sensitivities add to this low grade inflammation

    • Inflammation is a kind of chronic activation of the immune system and can be caused by a variety of environmental, stressor, or gut microbiome issues. It is possibly related to a sensitivity to gluten or a protein found in cows dairy called A1 casein

    • Key to knowing whether this is involved is if you have other symptoms that indicate an immune problem. This could be headaches, vitamin D deficiency, gluten antibodies, elevated DHEA and androstenedione.

    • Thyroid hormones enter our cells and change the way every cell metabolizes. It rules the rate at which our metabolism functions

    • Hypothyroidism (slow thyroid), is clearly associated with insulin resistance

    • Much more common for PCOS patients to have thyroid issues: specifically Hashimotos which is the auto-immune type & related to low grade inflammation

    • It is essential that your thyroid to be healthy to heal PCOS 

    • You need t3 thyroid hormone to ovulate  

    • Insulin has two main roles:

      • Take sugar from blood & put it in cells to keep blood sugar levels down and

      • It blocks & slows the rate of fat breakdown because its an anabolic hormone which helps us to grow tissue & store energy.

    • Slow thyroid = slow metabolic rate + high insulin (blocking of fat breakdown) and this is why its so much harder to lose weight especially around the abdomen

    • Your thyroid and ovaries need minerals to regulate properly. Deficiencies in iodine & zinc can disrupt thyroid regulation & impede ovulation

    • Treat underlying thyroid or adrenal issues and nutrient deficiencies as well as insulin resistance and inflammation if present

    • Lean PCOS is a spectrum of the same condition. 

    • Leaner people with PCOS have normal fasting insulin levels, but they often secrete much more insulin after the consumption of glucose compared to those without PCOS. 

    • They tend to have a Hypersensitivity to insulin.

    • 50% of those with lean PCOS also have reactive hypoglycemia where their blood sugar drops sharply about 1-2 hours after eating along with increased hunger. This is an early marker of potential PCOS and insulin resistance.

    • Measured by markers such as HOMA-IR, QUICKI, Hyperinsulinemic Glycemic Clamp = Ratios, Avoid tests like HBA1c & fasting glucose (which are normal in lean PCOS)

    • Some people experience PCOS symptoms when they stop using hormonal contraceptives

    • Some (not all) types of birth control use synthetic progestins that have a “high androgen index,” which means they are testosterone-like.

    • They are androgenic or “masculinizing” and cause symptoms such as acne, hair loss, and other psychological effects. 

    • Progestins with a high androgen index include levonorgestrel (many pills, Norplant implant, Mirena hormonal IUD, and the morning-after pill), norgestrel, gestodene, desogestrel, norelgestromin, norethindrone, and etonogestrel (many pills, Nuvaring, Nexplanon implant).

    • Body responds well with natural treatments like diet & supplements within 6 or so months, unless there are other issues (b12 deficiency, thyroid problems)

    • These subtypes are not always distinct and often overlap

    • Explore which factors are most impactful for you and treat multiple subtypes if applicable

    • Addressing one subtype is likely to improve another subtype

How Charting Helps with PCOS

  • Confirm if you are ovulating and when

  • Measure estrogen through observing cervical fluid and quality of menses

  • Measure progesterone through observing the luteal phase, basal body temperature, and premenstrual spotting

  • Measure thyroid health through basal body temperature (resting metabolic rate)

  • Track symptoms of inflammation and insulin resistance

  • Watch how charts respond to treatments

PCOS is a complex condition,
but we DO have options.