What is polycystic ovary syndrome (PCOS)? It is a complex endocrine disorder that affects 20 to 30 percent of women. In medicine, we use the term syndrome to describe a collection of signs and symptoms that don’t necessarily have a single identifiable cause or pathological process. PCOS causes the sex hormones in women to become unbalanced for reasons we still don’t quite understand. Irregular periods and signs of excess androgens (testosterone) are the telltale signs of PCOS. Not only will PCOS put you at risk for weight gain, acne, and excess hair growth, it is the number one most common reason for infertility. PCOS interferes with fertility by blocking regular monthly ovulation. After menopause, PCOS continues to put women at greater risk of heart disease, metabolic syndrome, and diabetes.
Sadly, polycystic ovary syndrome goes widely undetected and treated in up to 70 percent of those who suffer. I want to change this statistic by educating women about the complexity of PCOS. In this article, I talk about the various criteria that lead to a PCOS diagnosis, common PCOS signs and symptoms as well as PCOS solutions.
Prefer to watch rather than read? Watch my full PCOS series here on YouTube
How Do I Know If I Have PCOS?
There are some particular signs that your doctor looks for when diagnosing polycystic ovary syndrome. One of the reasons why PCOS can often go undiagnosed is because the signs and symptoms detailed below are not present in every woman with PCOS. Furthermore, there are four different diagnostic criteria, which I will discuss later in the article. First, let’s review the signs and symptoms common to PCOS.
- Hair in places that you don’t want it such as on your chin, jawline, breasts or belly. This can be caused by elevated androgens and is called hirsutism. It is present in about 50 to 80 percent of women with PCOS.1
- Oligomenorrhea – when your periods are more than 35 days apart. This indicates a problem with ovulation.
Diagnostic Tests for PCOS
- If you go to your doctor with one or more of the above signs, they can run a blood test to look at testosterone levels, including free testosterone and dehydroepiandrosterone (DHEA) to see if they are elevated. 80 to 90% of women with PCOS have hyperandrogenism.
- Your doctor can also confirm the lack of ovulation that causes the infrequent menstruation which we call oligomenorrhea. You can test by looking at luteinizing hormone (LH), the hormone involved in ovulation. You can also test progesterone. Low levels on day 21 or 22 of your cycle can indicate that ovulation has not yet occurred. In women who don’t have PCOS, progesterone levels should be 10 or higher on day 21 or day 22. It is important to note here that there are some women with PCOS who have a regular period but tests indicate they have not ovulated. However, 80 to 90% of women with polycystic ovary syndrome have infrequent periods, known as oligomenorrhea.
Your doctor uses an ultrasound to look at your ovaries to look for PCOS morphology, which means they look at the shape and structure. In many women with PCOS, the ovaries tend to be a little enlarged and on the edge of the ovary there will be a classic chain of cysts that look like a string of pearls. These cysts are small, about 8 mms on average. Often there are around 12 of these tiny cysts all around the edge of the ovary.
Difficulties with Diagnosing PCOS
It is difficult to diagnose PCOS, which is why many women go underdiagnosed. Not all women have hirsutism, for example. Other women have polycystic ovaries with cysts and infrequent periods but don’t have elevated androgens. Unfortunately, there is no single blood test that determines whether you have PCOS or not. This is why it is called a syndrome which groups different types of problems that women have. It is important to note though that polycystic ovary syndrome is more common in women who are obese. 1 in 3 have PCOS compared to women with a lean body where the occurence is 1 in 20.
Additionally, there are different criteria to diagnose PCOS correctly. I use the Androgen Excess and PCOS Society criteria2 which is listed as follows:
- presence of hyperandrogenism (clinical and/or biochemical)
- ovarian dysfunction (oligo-anovulation and/or polycystic ovaries)
- the exclusion of related disorders.
The Rotterdam criteria3 and the National Institute Health (NIH)4 consensus are the others.
Different Patient Types in Polycystic Ovary Syndrome
There are four main phenotypes or patient types in PCOS:
- Classical PCOS: clinical evidence of acne or hirsutism or biochemical evidence of high androgen levels (testosterone, high testosterone) + oligomenorrhea + polycystic ovary with classic string of pearl cyst presentation
- Second presentation type: clinical or biochemical evidence of hyperandrogenism + oligomenorrhea but what is different in this presentation is there is no clinical evidence in the form of ultrasound, i.e. no confirmation of cysts.
- Third presentation type: ovulatory PCOS, which means women have a clinical or biochemical presentation of hyperandrogenism + ultrasound evidence of polycystic ovary yet have completely normal, regular cycles, or there is no surge of LH mid cycle
- Fourth presentation type: non-hyperandrogenic presentation but women have oligomenorrhea + ultrasound evidence of polycystic ovaries.
As you can see from the above list, there are variations in the presentation of PCOS. While the majority of women have oligomenorrhea (infrequent periods) there are some who have regular periods and still have PCOS. They would be phenotype 3 or 4.
PCOS and Insulin Resistance
Insulin resistance is a very important topic to discuss when it comes to PCOS. While insulin resistance is not used to make a PCOS diagnosis, around 50 to 80 percent of PCOS patients have high testosterone and high insulin. Insulin resistance makes it hard for women to lose weight. An optimal fasting IR should be between 3 and 7.
PCOS, Cardiovascular Risk and Other Risk Factors
One of the strongest motivators for me to educate women about polycystic ovary syndrome is because of the increased risk of heart disease that it confers. I really want women to care about heart disease because it kills us more often than breast cancer. Unfortunately, PCOS often gets categorized as a “fertility disorder”, which means that once women are no longer in their childbearing years, there is less attention given to their PCOS both by women and their doctors alike. However, it is imperative that women are made aware that PCOS confers a greater risk of cardiovascular disease in women with phenotypes 1 to 3 listed above having the greatest risk.
PCOS Management and Treatment
Now to the good part about how you can manage and control your PCOS symptoms. Back in medical school, when I first went through training on PCOS, I was taught two things. First you ask a woman if she wants to get pregnant or not. If she does not want to get pregnant, then you prescribe the birth control pill. (If you follow me on social media, you probably know how I feel about the birth control pill.) If she does want to get pregnant, then you give her metformin. Metformin is an insulin sensitizer, for those with insulin resistance, often seen in diabetes/prediabetes/metabolic syndrome. Metformin can help women with PCOS ovulate and improve their glucose and insulin homeostasis.
As far as conventional medicine, those are the main treatment options. Women who are trying to get pregnant may also be referred to a reproductive endocrinologist (fertility specialist) for hormone therapy and/or in vitro fertilization (IVF).
Based on my extensive clinical experience, there are many natural solutions, including nutraceuticals that can help manage PCOS symptoms such as hyperandrogenism, weight loss resistance and insulin resistance.
Natural Solutions for PCOS
Let’s take a look at what is proven to make a difference.
Diet is the first thing that I address in women with PCOS. I recommend a diet high in vegetables, high in fiber and low in processed. It is important not to go too low with the carbs because the adrenals and thyroid need them for proper functioning. Prebiotic fiber is also important because there is a strong connection between gut health and hormone balance. If you reduce the glycemic load of your food and reduce the carbohydrates, inside of seven days you can significantly reduce your testosterone levels. Eating a low-glycemic index food plan reduces androgens by up to 20 percent.
Anywhere from 60 to 80% of women with PCOS are insulin resistant but not all of them. I believe that intermittent fasting is a great first-line therapy for patients with polycystic ovary syndrome. When we look at the literature, there’s not as much literature on PCOS and intermittent fasting but there are so many randomized trials showing the benefits of intermittent fasting in terms of its metabolic benefits that I think it’s proven enough to use it for PCOS.
Exercise and PCOS
With PCOS, diet and exercise are proven to ease the decree. As little as one 20-minute brisk walk per day can result in a 7 percent weight loss. Even in adolescent girls with PCOS, weight loss corrects irregular periods, normalizes androgens, and improves cardiovascular risk factors. Studies found that yoga was more effective than other forms of exercise at improving insulin resistance in PCOS.5
I think a lot of people get frustrated because when you’re insulin resistant and when you have PCOS it can feel like you’re pushing a rock up a hill in terms of trying to lose weight and what we know is that even a 5% reduction in weight, I care more about fat loss than weight loss, but even a 5% reduction is associated with all of these metabolic benefits so we’re not talking about you know you got to lose 50 pounds or hundred pounds, even 5% makes a big difference when it comes to PCOS.
What Is the Role of Inflammation in PCOS?
A new paradigm is emerging that places excess inflammation as the central aggressor, driving hyperandrogenism and insulin resistance. Inflammation6 may be the common thread when it comes to PCOS presentations, and can help explain the inconsistencies seen in the old model as well as accounting for the differing phenotypes. Inflammation due to poor microbiome or due to less than optimal diet (diet of high carbs and saturated fats) can lead to the metabolic aberrations and ovarian dysfunction seen in PCOS. A major cause behind this inflamed state is dysbiosis. This is an imbalance in your gut flora caused by too few beneficial bacteria and an overgrowth of bad bacteria, yeast, and/or parasites. With a functional medicine approach to polycystic ovarian syndrome, the target becomes gut dysbiosis and the reduction of inflammation.
Supplements and Nutraceuticals for PCOS
Berberine is a bioactive found in several plants including European barberry, goldenseal, Oregon grape, and others—that has been shown to help lower blood sugar and decrease total and LDL cholesterol.7 When taken for 12 weeks, it reduces weight by 5 pounds in obese patients.8 Berberine also helps activate thermogenesis (heat production) in white and brown fat.9
In addition, berberine is superior to metformin, a common prescription for PCOS, at improving lipid parameters, reducing waist-to-hip ratio, and increasing SHBG in PCOS patients.10
Dose: 500 mg, three times per day. I recommend pulsing for 6-8 weeks, then take at least a 2 week break. Combine berberine with milk thistle at a dose of 105 mg to improve effectiveness.
Fish oil and chromium are also associated with insulin sensitivities as is lipoic acid. As you can see, there are lots of different ways to work on the insulin signal. I advise working with your doctor or functional medicine practitioner to determine what is right for you.
Two inositol supplements you can get at the drugstore or health food store show promise in correcting PCOS: D-chiro inositol (DCI) and Myo-inositol (MI). Inositol is a naturally occurring B-complex vitamin known to improve insulin sensitivity.11 Women with PCOS appear to be deficient in DCI. Evidence supports that overweight women with PCOS be given the combination of DCI and MI first, prior to any prescription therapy. DCI has been shown in women with PCOS to cut free testosterone by more than half and lowered blood pressure and triglycerides in eight weeks or less.12 DCI also works in lean women with PCOS.13 Recommended dose: DCI 600 mg twice per day (but you can also find DCI in carob, buckwheat, and grapefruit) and myo-inositol at a dose of 2 grams once or twice per day).
Chromium is a mineral that acts as an insulin sensitizer, which means it helps to reverse insulin resistance and lowers both your serum insulin and glucose levels when they are high. Folks with type 2 diabetes, the type that results from insulin resistance, have lower blood chromium levels compared with nondiabetic people. Chromium is a safe supplement worth trying if you are insulin resistant. I recommend a dose of 200 to 1,000 mcg per day of chromium picolinate.
Foods high in chromium include eggs, nuts, green beans, and broccoli.
Vitamin D is a fat-soluble vitamin that is present in eggs and fish. It is added to other foods, such as milk, and is also available as a dietary supplement. I recommend about 2,000 IU per day. Vitamin D deficiency is emerging as a factor in the metabolic disturbance of PCOS. In fact, 44 percent of women with PCOS are vitamin D–deficient, compared with 11 percent of controls.
Supplements that reduce and resolve inflammation include fish oil, borage oil, evening primrose oil as well as specialized proresolving mediators (SPMs). For more information on these, including dosage, click here.
Make sure to add in extra fiber to your diet to expel excess testosterone and eat more zinc-rich foods to bolster ovulation, fertility and menstruation.
Although full of complexities, polycystic ovarian syndrome responds very well to a combination of targeted food plan, exercise, de-stressing, supplements, and other personalized lifestyle recommendations. Unfortunately, many doctors are not well-versed in the literature on nutrition, nutraceuticals and lifestyle interventions and often end up telling women with PCOS to exercise more and eat less, which misses the mark completely, leaving women frustrated and confused. If you suspect you may have PCOS, it is important to find a collaborative doctor with experience in treating this complex syndrome. A great place to start to make sense of your symptoms is my book THE HORMONE CURE in the chapter on Excess Androgens. If you would like to work directly with me and/or my colleagues at the Marcus Institute of Integrative Health, click here for more information and to sign up for priority updates.
1. Diamanti-Kandarakis E, et al., Insulin Resistance and the Polycystic Ovary Syndrome Revisited: An Update on Mechanisms and Implications. Endocrine Reviews, 2012, 33(6), 981–1030. https://doi.org/10.1210/er.2011-1034
2. Azziz R, et al., The Androgen Excess and PCOS Society criteria for the polycystic ovary syndrome: the complete task force report. Fertility and Sterility, 91(2), 2008, 456-488. https://doi.org/10.1016/j.fertnstert.2008.06.035
3. The Rotterdam ESHRE/ASRM‐sponsored PCOS consensus workshop group, Revised 2003 consensus on diagnostic criteria and long‐term health risks related to polycystic ovary syndrome (PCOS), Human Reproduction, 19(1), 2004, 41–47. https://doi.org/10.1093/humrep/deh098
4. Zawadsky J, Dunaif A. Diagnostic criteria for polycystic ovary syndrome. In: Dunaif A, Givens JR, Haseltine FP, Merriam GR, ed. Polycystic ovary syndrome. Boston: Blackwell Scientific. 1992. p. 377-84.
5. Nidhi R, et al., Effect of a yoga program on glucose metabolism and blood lipid levels in adolescent girls with polycystic ovary syndrome. International Journal of Gynaecology and Obstetrics. 2012, 118(1):37-41. doi: https://doi.org/10.1016/j.ijgo.2012.01.027
6. Ulrich J, et al., Impact of Autoimmune Thyroiditis on Reproductive and Metabolic Parameters in Patients with Polycystic Ovary Syndrome. Experimental and Clinical Endocrinology & Diabetes. 2018 Apr;126(4):198-204. doi: https://10.1055/s-0043-110480.
7. Zhang Y, et al., Treatment of type 2 diabetes and dyslipidemia with the natural plant alkaloid berberine. The Journal of Clinical Endocrinology & Metabolism. 2008, 93(7): 2559-2565; Yin J, et al., Efficacy of berberine in patients with type 2 diabetes mellitus. Metabolism. 2008, 57(5): 712-717; Zhang H, et al., Berberine lowers blood glucose in type 2 diabetes mellitus patients through increasing insulin receptor expression. Metabolism. 2010, 59(2): 285-292
8. Hu Y, et al., Lipid-lowering effect of berberine in human subjects and rats. Phytomedicine. 2012 19(10):861-7. doi: https://10.1016/j.phymed.2012.05.009.
9. Zhang Z, et al., Berberine activates thermogenesis in white and brown adipose tissue. Nature Communications. 2014 5(5493). doi: https://10.1038/ncomms6493.
10. Wei, W, et al., A clinical study on the short-term effect of berberine in comparison to metformin on the metabolic characteristics of women with polycystic ovary syndrome. European Journal of Endocrinology 166(1) 2012, 99-105
11. Nordio M, Proietti E., The combined therapy with myo-inositol and D-chiro-inositol reduces the risk of metabolic disease in PCOS overweight patients compared to myo-inositol supplementation alone. European Review for Medical and Pharmacological Sciences. 2012, 16(5): 575–81.
12. Nestler JE, et al., Ovulatory and metabolic effects of D-chiro-inositol in the polycystic ovary syndrome. New England Journal of Medicine. 1999, 340(17): 1314–20.
13. Iuorno MJ, et al., Effects of d-chiroinositol in lean women with polycystic ovary syndrome. Endocrine Practice. 2002, 8(6): 417–23.