Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder affecting women of reproductive age in the United States. The name is somewhat misleading, as ovarian cysts are not necessarily a requirement for diagnosis. PCOS is multifactorial in nature, with a genetic component and environmental influences known to be contributors towards syndrome risk. Women diagnosed with PCOS are at higher risk for insulin resistance and metabolic disorders, infertility, and obesity.

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CC: PCOS Diagnosis, Irregular Menstrual Cycles, Weight Gain, Acne, Painful Periods, Hair Thinning

Nia* was a 35-year-old female who had been diagnosed with PCOS a year prior to our initial consultation. Her symptoms that led to the diagnosis - irregular menstrual cycles, weight gain, acne, painful periods - had not been helped by the original treatment she had been given (oral contraceptives). Additionally, Nia had started to notice her hair was thinning and felt her acne was worsening and was now painful and cystic around her chin and jawline.  

Nia had a history of painful periods, PMS-related symptoms, and menstrual cycles that varied in length from 30-45 days. She and her husband had one son when she was 32 years old, and it was difficult for them to get pregnant as Nia found she wasn’t always ovulating. After 18 months of trying to conceive, she had an uncomplicated pregnancy and birth, though she reported she felt like she “never lost the weight” afterward. It took a year for her period to return after giving birth, and her periods have been painful and heavy since. Her cycles averaged about 40 days.

Nia’s OB-GYN diagnosed her with PCOS when she was 34 and suggested she start a combination oral contraceptive to help regulate her cycles and reduce her symptoms. Nia tried this for eight months and felt that other than having a 28-day cycle while taking it, none of her symptoms had changed, and some had gotten worse. Additionally, she reported she felt moodier than she used to and experienced symptoms she felt were almost like depression and that these symptoms had not gone away when she stopped taking the pill four months prior to our consultation. She had had two periods since stopping the pill, the first cycle being 75 days, the second being 40 days in length.

During a review of systems, Nia also brought up that she had ongoing digestive issues, including bloating and constipation, and often had food cravings for sugary, carbohydrate-rich foods. She felt that her energy went up and down all day, and she had recently tried to do intermittent fasting in an attempt to lose weight but was struggling with skipping meals.  

Nia ran her own business from home and managed a small virtual team, and while she had flexibility in terms of work hours, she admitted she sometimes had high-stress levels from building and scaling her business. She and her husband often ordered delivery for the sake of convenience, and she reported that they didn’t really prioritize grocery shopping and cooking. At the time of her initial consult, she was taking a multivitamin to try to “fill in the nutritional gaps,” as well as a greens powder she found online. She was not taking any medications.

Lab Work Results

The following specialty labs were run:

Comprehensive Stool Test

A Comprehensive Stool Test (the GI-MAP by Diagnostic Solutions) showed the following results: 

• Pancreatic elastase was low
• Fecal fat was high
• High beta-glucoronidase
• Elevated candida spp., opportunistic bacteria species
• Low commensal bacterial spp.

DUTCH Cycle Mapping + DUTCH Complete Test

Cycle mapping for a 38-day cycle showed no rise in progesterone, with no estrogen peak mid-cycle.

Additionally, the DUTCH test showed elevated testosterone and related androgen metabolites, elevated DHEA-S, and high 5alpha-reductase activity. Estrone and Estriol were low, and estradiol was within normal limits, with progesterone metabolites very low.

The 24-hour cortisol measurement piece of the test showed elevated cortisol throughout the morning and afternoon into the evening, with levels very low upon waking.

Additional Lab Results

Lab Analysis 

Nia's lab work points to a few different problems that are contributing to her symptoms.

Dysbiosis and Malabsorption

Nia’s stool test showed low pancreatic elastase and high fecal fat, indicating low digestive enzyme function and likely malabsorption. This can lead to not absorbing nutrients optimally from her diet and may cause bloating and digestive issues such as constipation. Her results also showed elevated candida spp. and opportunistic spp., with low commensal bacteria, indicating dysbiosis was present. A dysbiotic microbiome can cause constipation, inflammation, impaired detoxification ability, and even hormone imbalances and has been linked to the development of some cases of PCOS.

Hormone Imbalances

Nia had many hallmarks of a PCOS diagnosis present, including high androgens, low progesterone, and low sex hormone-binding globulin (SHBG). She also showed markers suggesting hypothyroidism (high TSH and low free T3), as well as elevated cortisol throughout the day and evening. Hypothyroidism and high-stress hormones can both contribute to hair thinning and can impact sex hormone imbalances in cases of PCOS. Dysfunction of the hypothalamic-pituitary-adrenal (HPA) axis has been suggested to play a role in the pathogenesis of PCOS, making it important to evaluate adrenal function as part of an integrative approach to managing the condition.  

Metabolic Markers

While Nia’s fasting insulin was on the high end of the normal range, her fasting glucose and HgbA1C were both elevated, indicating that Nia was dealing with insulin resistance that is commonly present in PCOS. Her potassium was also borderline low.  

Multiple Micronutrient Depletions

Nia had several vitamin and mineral depletions apparent on her micronutrients testing, including zinc, magnesium, vitamin D, vitamin B6, vitamin B12, glutathione, CoQ10, and potassium. Zinc, potassium, and magnesium deficiencies have all been linked to PCOS, and vitamin B6 is an important micronutrient for female sex hormone regulation.  

Interventions

Nia was firm that she was not interested in trying another form of oral contraceptive to manage her symptoms and wanted to focus on nutritional and lifestyle interventions as much as possible. Due to her hypothyroidism, we referred her to an endocrinologist to discuss options for supporting her thyroid, and Nia started taking Armour Thyroid 30mg per day.  Her therapeutic plan recommendations are listed below.

Supplementation

• Started magnesium glycinate, 400mg at night
• Started vitamin D3, 2000 IU once/day (Apex Energetics Liqua-D)
• Started comprehensive digestive enzyme to help support food breakdown and nutrient absorption (Apex Energetics Enzymix-Pro)
• Started having digestive bitters prior to meals to help stimulate stomach acid and digestive enzyme production.
• For 6 weeks, we added in Gi-MicrobX, an antimicrobial blend to help eradicate opportunistic microbes in the gut; we followed this up with probiotic rotations, including S. Boulardii and Lactobacillus/Bifidobacterium spp. In addition to prebiotic and probiotic foods in the diet.
• Started Ovasitol, a supplement containing the myo- and D-chiro forms of inositol, a compound that has been shown to improve ovulation, hormonal acne, and metabolic markers in women with PCOS. Research shows that taking the two forms together in the Ovasitol ratio of 40:1 is more beneficial for PCOS management than either form alone.  
• Started OvaBlend by Vitanica for 3 months, a blend of ingredients aimed to support ovulation and blood sugar regulation.  The blend includes green tea, cinnamon, and chromium, and saw palmetto.  

• Green tea has been shown to increase SHBG levels
• Cinnamon and chromium are beneficial for blood sugar regulation and insulin sensitivity
• Saw palmetto has been shown to help hormonal hair loss and acne by inhibiting the conversion of testosterone to its stronger form, dihydrotestosterone (DHT).

Nutritional Changes

Nutritionally, we emphasized an anti-inflammatory, whole food, nutrient-dense diet rich in fruits, vegetables, healthy fats, and protein.  

• We found a healthy meal prep service near Nia that she and her husband could use to pre-order healthy meals for the week if they felt like they didn’t have time to cook themselves.  
• Foods high in glucuronic acid, like apples, Brussels sprouts, cooked cruciferous vegetables, and oranges, were included to help reduce the high levels of beta-glucuronidase.  
• Additionally, we included functional fibers to help support the growth of beneficial gut bacteria, including sources of inulin, beta-glucan, and fructo-oligosaccharides.  
• Emphasis was on having quality protein (such as grass-fed beef, poultry, fish, and eggs), fat (such as avocado, olive oil, and flaxseed), and fiber with each meal to keep blood sugar in check while limiting sugar, refined carbohydrates, and fast food. We kept carbs on the low-moderate side (under 100-120g per day), as such an approach has been linked to beneficial outcomes for PCOS patients.  
• We had Nia focus on hydration and increasing her water intake as well.  
• We also focused on eating hygiene: chewing food well, slowing down and stepping away from work while eating, and taking a few slow breaths before starting a meal.

Lifestyle Recommendations 

• Nia started walking consistently every day, and after one month, started working with a virtual personal trainer 2-3x per week to do strength training at home.
• Additionally, we focused on bringing more “breaks” into Nia’s day, which involved short walks, getting outside, or doing something fun with her family that she enjoyed to break up her demanding work schedule.
• We had Nia incorporate stress reduction and nervous system regulation strategies, including breathwork, meditation, and bodywork (depending on her schedule), to help address her high stress levels and HPA axis dysfunction.

• After three months, Nia started to have a more consistent menstrual cycle (two cycles of 30 days), and we started incorporating some intermittent fasting, which has been shown to be beneficial for PCOS patients. We focused on 16:8 time-restricted feeding in the early follicular phase and in the luteal phase and did not do fasting in the estimated ovulation window or the 3-4 days leading up to her period.  
• Nia also started to see a holistic aesthetician and switched her skincare products to non-toxic, fragrance-free products to help support acne healing.  

Follow-Up Labs 6 Months Later

GI-MAP & Micronutrient Testing Follow-Up Results: All Within Normal Range

Nia’s micronutrient re-test came with all results within normal limits, demonstrating that her plan was helping restore her vitamin and mineral levels.

Additionally, her GI-MAP results improved to normal ranges:

• Pancreatic elastase was normal (initially low)
• Fecal fat was normal (initially high)
• Beta-glucuronidase was low (initially high)
• No detectable candida spp., opportunistic bacteria levels had fallen into normal ranges (initially, elevated candida spp., opportunistic bacteria species)
• Normal commensal bacterial spp. growth (initially low)

Follow-Up Interpretations and Continued Interventions

Over the course of six months, Nia implemented all nutritional, supplemental, and lifestyle recommendations with regular check-ins and guidance. The meal prep service was invaluable, as it gave Nia and her husband back time and energy and ensured they had healthy meals to support Nia’s goals. Nia found she really enjoyed strength training and doing pilates at home, and exercise became a regular part of her routine after a month or two.  

All of Nia’s lab markers returned to normal ranges, with the exception of DHEA-S, which remained slightly high. At the 6 month mark, Nia had had 4 consecutive 30-day cycles and had ovulated the last three of them, tracked with regular ovulation testing. Her periods were not painful, with only some mild discomfort on the first day of menstruation. 

Her acne had improved dramatically, with almost no sign of cystic nodules by the 6-month mark. Her aesthetician and new skincare regimen were helping to prevent any long-term scarring, and Nia was happy with her progress so far.  She had recently invested in a red light unit and was intending to start using it to help her skin heal even more.  

Nia’s digestion had improved by the 2-3 month mark, with her having regular bowel movements 1-2x per day with minimal sugar cravings. Adding in intermittent fasting continued to help reduce sugar cravings and helped her lose some weight, for a total of 18 pounds over the course of 6 months working together.   

While Nia’s hair hadn’t quite grown back to what it had been pre-pregnancy, she felt like it had started to come back and was healthier, and she noted she had new growth in the temple regions where it had been thinning the most.  

Moving forward from the 6-month lab re-check, Nia planned to continue her nutritional and supplemental approach as she felt it was simple to maintain and fit her lifestyle well. We spoke about cycling back in carbohydrates around her workout load to ensure she didn’t stay low-carb for too long, and she planned to check in monthly to make sure everything was on track. Nia’s endocrinologist was continuing to monitor her thyroid function and medication as well.  

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Summary

This case highlights the multifactorial nature of PCOS, as symptoms vary widely from person to person, and the pathogenesis often involves systems in the body besides the reproductive organs. In Nia’s case, her gut health and HPA dysfunction played a role in her symptom development and were not addressed by simply introducing an oral contraceptive pill. Nia had to make a lot of changes in her lifestyle in order to get the results she wanted, and it was not always a linear path; however, with consistency and guidance, she was able to start cycling regularly again and address her metabolic and gut health along the way.