You may have noticed more and more women with PCOS walking into your office these last several years. In fact, about 5 million women in the USA have it, and that number shows no signs of slowing down any time soon.

PCOS isn't just a diagnosis; it's an experience that affects every aspect of your patient’s well-being—from their physical health to their emotions. It's a condition with lots of misconceptions, often leaving those affected feeling isolated and overwhelmed. 

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What is PCOS?

PCOS, or Polycystic Ovary Syndrome, happens when a woman’s hormones are out of balance. Imagine the body as a factory that makes different kinds of hormones. In PCOS, the factory gets a little mixed up and makes too much of some hormones called androgens, which are often thought of as "male hormones," even though females have them too.

Because of this mix-up, the ovaries (where eggs are stored in tiny sacs called follicles) might not release eggs the way they're supposed to. Instead of the follicles opening up to release an egg each month, they can turn into small cysts (which are like tiny liquid-filled balloons) on the ovaries. This can make periods really irregular or even stop them from happening.

Signs and Symptoms of PCOS

Women will experience at least 2-3 symptoms from the following list. In fact, this is the minimum amount of symptoms required for diagnosis. The most common symptoms fall into 3 categories:

• Menstrual symptoms
  • Irregular periods - defined as cycles that are > 35 days apart or <8 cycles in a year
  • Heavy menstrual bleeding to the point of interfering with daily routine
• Signs of excess androgens (“male” hormones”)
  • Acne
  • Hair growth on the face and body
  • Hair thinning on the scalp 
• Polycystic ovaries seen on an ultrasound scan
  • Having 12 or more small cysts in each ovary that are 2-9 mm across and/or having ovaries that are larger than 10 milliliters in size

While the following are not necessary for diagnosis, they are still quite common:

• Skin darkening in the armpits, neck, or groin
• Infertility - which is due to the lack of ovulation
• Weight fluctuations - typically weight gain and obesity
• Depression and/or anxiety
• Trouble with sleep quality

Not every woman with PCOS experiences all the associated signs and symptoms. The combination can vary from one woman to another. Also, other health conditions can lead to similar symptoms, making PCOS challenging to identify accurately.

The Root Causes of PCOS

Understanding the root causes can help you develop treatment plans that are personalized to your patients. 

Genetics:

A family history of diabetes or obesity may predispose individuals toward this condition. Additionally, women with a mother or sister with PCOS are at a higher risk themselves. Yet, it's important to recognize that genetics isn't the full story. 

Insulin Resistance:

Think of insulin as a key that opens the doors of the cells to let in glucose to use as energy. In PCOS, it's as if the locks on the doors are a bit rusty. The keys (insulin) can't open the doors (cells) properly, so the body has to make more keys to try and get the glucose inside.

This problem, where the keys have a hard time opening the doors, is called insulin resistance. Because there are too many keys floating around (high insulin), the body starts to act differently. 

In the ovaries, high levels of insulin can lead to an overproduction of androgens (like testosterone). Even though androgens are normally present in women in small amounts, an excess can throw off the hormonal balance, leading to PCOS. 

Low-Level Inflammation

PCOS is linked with low-level inflammation in the body. Inflammation isn’t always bad, and in fact is the body's natural response to invaders. However, in PCOS, the inflammation is like having a silent alarm that's always on. This constant low-level inflammation is another contributor to the ovaries making too many androgens.

Chronic inflammation might also play a role in making the body resistant to insulin. This cycle of inflammation, hormone imbalance, and insulin resistance is part of what makes PCOS a complex condition.

How to Diagnose Polycystic Ovary Syndrome (PCOS)

PCOS must be diagnosed by a healthcare provider who will assess symptoms and medical histories and perform diagnostic evaluations. 

Step 1: Use the Rotterdam Criteria:

Two out of three specific markers must be present to confirm a diagnosis: 

1. Irregular or absent ovulation (manifesting as irregular or missing menstrual periods)
2. Signs of hyperandrogenism (an excess of male hormones)
3. The detection of polycystic ovaries on ultrasound

PCOS can look different depending on the individual, and not everyone will experience the same set of signs or symptoms. This criteria ensures that a wider range of women are recognized and properly diagnosed.

Step 2: Digging Deeper with Testing to Understand the Root Cause of PCOS

Several lab tests can help us understand the root cause of your patient’s PCOS. 

Thorough Hormonal Evaluations

Typically, bloodwork is run first. A thorough panel testing at least LH (Luteinizing Hormone), FSH (Follicle Stimulating Hormone), and testosterone gives important initial information about the balance of the sex hormones. 

In non-PCOS women, an LH:FSH ratio is 1:1. In PCOS, the ratio is typically greater than 1, where the LH value is more than the FSH value. This increase contributes to the ovaries producing more androgens. While a common finding in most women with PCOS, this ratio alteration is not part of the diagnostic criteria.

An expected testosterone level for a woman without PCOS is in the range of 15 to 70 ng/dL. In PCOS, testosterone levels can be much higher, although usually not above 150 ng/dL (higher than 200 ng/dL in a biological female warrants further evaluation by a physician).

Here are hormonal blood work panels you can start with:

• Female Hormone Panel - Precision Point
• Female Hormone Panel - BostonHeart Diagnostics
• FSH & LH + Testosterone, Free & Total w/ SHBG - Access Medical Labs

While hormone blood tests are useful, these hormones fluctuate throughout the month and can vary between women, so it's hard to rely on these tests alone to know for sure if someone has PCOS. 

Urine and saliva testing can give more in-depth results by assessing the body’s hormone production and hormone metabolism. The following are all thorough hormonal testing options:

• DUTCH Plus - Precision Analytical (DUTCH)
• DUTCH Cycle Mapping - Precision Analytical (DUTCH)
• Sex Steroid Metabolites + UDH II - ZRT Laboratory
• Saliva Hormone Opendx Supreme - Access Medical Labs
• Saliva Hormone Female Evaluator (11 Days) - Access Medical Labs
• Saliva Female Hormones - Ayumetrix

Cardiometabolic Testing    

The cardiometabolic risk associated with PCOS calls for a comprehensive panel to screen for dyslipidemia (cholesterol issues), hyperglycemia (blood sugar imbalance), insulin resistance, and inflammation. 

The following panels can help assess these risks:

• HOMA-IR - BostonHeart Diagnostics
• Metabolomic Profile - Doctor’s Data
• Inflammation Panel - Ayumetrix

The Ultimate Treatment Plan For PCOS

By focusing on the root causes, we can forge a path toward symptom management and enhanced well-being. Here is the step-by-step process for treating this complex condition:

1. Significantly Reduce Inflammation

Here’s why this is important: 

Inflammation is likely a contributing factor to insulin resistance and can also have a negative effect on the ovaries, specifically in the development of the follicle and ovulation.

How do you do this:

An anti-inflammatory diet is the best first place to start when attempting to reduce inflammation.

• Add: whole foods like colorful fruits and vegetables, whole grains, lean proteins, and healthy fat sources like avocados, nuts, seeds, and olive oil to combat inflammation.
• Avoid/Reduce: ultra-processed foods, sweets, sugary drinks, foods with trans or saturated fats (found in some meats, deep-fried foods, and baked goods), refined grains (like white bread), and excessive alcohol.
• Include: herbs and spices like garlic, ginger, turmeric, cinnamon, and cayenne pepper, which can provide additional anti-inflammatory benefits.

Supplements can also help shift the body into more of an anti-inflammatory mode. Omega-3 Fatty Acids, for example, can aid in reducing inflammation and potentially enhance insulin sensitivity. A daily intake of at least 2 grams of a high-quality fish oil supplement is typically required to achieve an anti-inflammatory effect. 

Note that each patient is different, and the dose should be modified accordingly. 

2. Reverse the Insulin Sensitivity

Here’s why this is important:

Since insulin sensitivity plays such a significant role in the development of PCOS, reversing this process is important so that we can halt the negative effects that poor blood sugar regulation has on the ovaries.

How do you do this:

Medications can be really useful here when appropriate, specifically the use of Metformin, which is an oral insulin sensitizing agent - basically, it is a drug prescribed to help support the proper use of insulin and to help lower blood sugar. It has also been shown to support healthy ovulation in the PCOS population.

Diet is also essential to get right in order to reestablish healthy blood sugar regulation. Specifically:

• Include fiber-rich choices like berries, greens, beans, and whole grains, which can slow glucose absorption and support insulin sensitivity. The recommended amount for a woman is 25g of fiber per day.
• Don’t skip breakfast. Research shows a correlation between skipping breakfast and a higher rate of insulin sensitivity.  
• Reduce the consumption of high-glycemic index foods like potatoes, rice, and sugary treats that lead to quick blood sugar rises. Research correlates these types of foods with a higher insulin resistance rate.

Regular physical activity has been shown in research to help reduce insulin sensitivity. Aerobic exercises, resistance training, and HIIT enhance insulin sensitivity in unique ways, which is important for metabolic health. Aerobics improve glucose use and circulation, resistance training strengthens muscles and boosts insulin response, and HIIT significantly betters glucose metabolism and insulin sensitivity, also reducing harmful fatty acids. 

Specific supplements can also enhance your patient’s efforts at supporting healthy insulin production and use. 

Minerals like zinc, magnesium, and chromium support insulin function and metabolic wellness with their direct and indirect effects on how much insulin our body makes and how well it works. Research shows the following recommended doses:

• Magnesium: 200-400 mg daily
• Chromium: 200-1000 mcg daily
• Zinc: 25mg daily

Some other nutrients can also be effective additions to the treatment plan:

• Inositol: Combining myo-inositol (2000 mg) and d-chiro-inositol (50 mg) (a ratio of 40:1) twice daily has been noted for its insulin sensitivity and ovarian function benefits.
• Alpha-Lipoic Acid (ALA): 400 mg daily, taken on an empty stomach, can support insulin sensitivity, especially in those who have a family history of diabetes.
• Berberine: 500 mg two to three times daily before meals can help reduce insulin resistance and help regulate the menstrual cycle - berberine has potential medication interactions, highlighting the importance of healthcare guidance.
• NAC (N-Acetylcysteine): This antioxidant, at 1,500 mg daily, can lead to improved insulin sensitivity in patients with PCOS.

Stress also has a significant effect on insulin resistance. It interacts with at least six different metabolic pathways! Therefore, stress management should certainly be a part of a thorough treatment plan. Meditation, yoga, deep breathing, and cognitive behavioral therapy (CBT) are all beneficial.

3. Rebalance Hormones

After the first two steps, hormones will likely start to regulate on their own. However, in many instances, practitioners might want to further support hormone regulation. 

Here’s why this is important:

Without proper hormone balancing, ovarian health and ovulation can be negatively affected. Plus, hormone imbalance is the reason behind many of the uncomfortable PCOS symptoms.

How do you do this:

If fertility is not top of mind, oral contraceptives can help regulate the menstrual cycle and reduce androgen levels. This is a great option for reducing many PCOS symptoms, such as acne, hirsutism (facial hair growth), and hair thinning, since it directly alters hormone production. 

However, oral contraceptives won’t fix the root causes discussed above and may not be a suitable option for all patients, especially those who smoke or have significant cardiometabolic conditions/risk factors.

For non-pharmaceutical options, certain herbal remedies can be utilized effectively. Spearmint tea, for example, has been shown to lower testosterone levels and alleviate hirsutism (facial hair) at just two cups a day.

Vitex (Chaste Tree Berry) is also a well-known herbal option, known for its cycle-regulating and ovulation-enhancing gifts, starting at 500-1000 mg daily to invite regularity and fertility.

4. Specifically for Fertility:

Treating the root causes as described above will naturally lead to boosted fertility as well. However, if fertility is a primary goal, medications should be considered to speed up the process. 

Clomiphene citrate (Clomid) or Letrozole (Femara) can be prescribed. Both aim to boost ovulation but through different pathways.

Clomiphene Citrate is a selective estrogen receptor modulator (SERM) and works by blocking estrogen receptors in the brain, tricking the body into producing more hormones that stimulate ovulation - luteinizing hormone (LH) and follicle-stimulating hormone (FSH). 

Letrozole, on the other hand, is an aromatase inhibitor and directly reduces estrogen levels by inhibiting an enzyme called aromatase, which stops the conversion of androgens into estrogens. Lower estrogen initiates a feedback loop in the brain, leading to an increased production of LH and FSH and, therefore, ovulation stimulation. 

The Serious Risks of Untreated PCOS

Ignoring PCOS can lead to serious risks such as the increased risk of:

• type 2 diabetes due to increased insulin resistance over time
• hypertension (high blood pressure) and hyperlipidemia (high cholesterol), both of which are significant contributors to cardiovascular disease
• non-alcoholic fatty liver disease, a condition that can escalate into dangerous liver issues
• hormonal imbalances and inconsistent ovulation leading to infertility 
• pregnancy complications like elevated risks for miscarriages, gestational diabetes, and preterm births
• certain cancers - endometrial, ovarian, and breast

PCOS Case Study

Read about a real case study here:

How Nia Was Able to Overcome PCOS Naturally

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Key Takeaways

• Treating PCOS in patients can be a complex challenge. A root cause approach can significantly enhance your patients' health outcomes, providing relief from symptoms. 
• Encouraging patients to nourish their bodies with healthy foods, reduce stress, carefully select supplements, and use medications when necessary can set them on a transformative path toward better health. 
• As a healthcare practitioner, your support can empower patients to navigate PCOS with confidence, ensuring it's a condition they manage rather than one that defines them.