PCOS: Beyond What Your Doctor Tells You

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Wonder if you have PCOS? Take the quiz:

On a regular basis, I hear from women all over the planet who have a PCOS diagnosis and want more than what their doctor offered. These smart women say things like:

  • “My doctor offered birth control hormones to regulate my period, but I know that’s not going to solve the PCOS, it will only mask it.”
  • “I asked my doctor what I can do to heal this, and she said there really isn’t anything to do for intervention until I want to have kids. I am only 23 and not ready to have kids, but I want to take care of this now and not wait until then!”
  • “My doctor said to lose weight and exercise, however, I need to know more about how to eat for PCOS and not just go on a diet. Diets don’t work for me.”
  • “I was put on birth control hormones as a teenager to control my periods, and now I am 32 and I want to go off them in order to get pregnant. But this also terrifies me and I want to do it successfully!”
  • “I am only 16 and I don’t want to go on birth control pills but my doctor says that’s all I can do.”

It’s impressive to see women take charge of their health and seek options beyond what their doctors offer. And they are right to do so because there is a lot you can do to actually heal and reverse PCOS symptoms and lab markers. It’s also a very good idea to tackle this project to avoid the long-term risk factors of untreated PCOS.

So, you have a PCOS diagnosis

Once you have this diagnosis, it is likely that your provider will recommend one or all of the following treatments:

  • Lose weight (magic wand not included). 
  • Birth control pills to “regulate” your period and reduce the number of androgens circulating around your body.
  • Synthetic progestin therapy to reduce the heavy bleeding when you DO get a period.
  • Metformin, an insulin-sensitizing drug to reduce insulin excess and prompt you to ovulate.
  • Spironolactone (an androgen receptor blocker) to help reduce the symptoms of hair loss, excessive facial and body hair, and acne.

If you want to become pregnant, the recommendations will shift:

  • Lose more weight (if you haven’t magically cracked your weight loss code already).
  • Take Clomid (a drug that stimulates ovulation) with your Metformin.
  • “Run, don’t walk” to the nearest fertility specialist for insemination or in vitro fertilization (IVF).

Sadly, this menu of treatments hasn’t changed in the last 20 plus years of practice despite emerging research that describes the various underlying causes of PCOS. By knowing the causes, we can reduce and possibly reverse the impact of this condition.

Here I discuss the most common causes of PCOS, and the tests to help identify these conditions. For each one, the primary way to heal is through “lifestyle medicine,” which consists of targeted adjustments in your eating, sleeping, movement, and other daily routines. My Reclaim Your Hormones program is a great place to start.

Meet the most common root causes of PCOS

If you have a PCOS diagnosis, you likely have one or more underlying causes. It is important for you to address each one to improve your health and reduce or reverse your symptoms and associated risks.  

Here is a list of the most common PCOS triggers and causes:

  1. Insulin resistance
  2. A disrupted gut microbiome
  3. Immune dysregulation and inflammation
  4. Toxic burden from impaired detox
  5. Post-pill amenorrhea
  6. Circadian rhythm out-of-whack
  7. Adrenal hormone imbalance

Now let’s delve into each of these root causes and how to test for them.

1. Insulin resistance

Insulin resistance refers to your body’s reduced ability to respond to insulin. Chronic high blood sugar raises insulin, which eventually remains elevated.  High insulin levels cause your ovaries to produce higher than normal levels of testosterone. Not all women with high insulin respond in this way because your genes play a role in whether or not you develop PCOS.  

How to test
  • Fasting insulin (should be less than 10, the functional ideal is around 5)
  • Fasting glucose (should be less than 99, the functional ideal is under 90)
  • Hemoglobin A1C (should be less than 5.4, the functional ideal is 5.0)
  • Two-hour oral glucose and insulin tolerance test (this is a challenge test to see how you handle a high sugar load)
  • SHBG (sex hormone binding globulin) – reduced with both elevated androgen levels AND insulin resistance
  • Serum magnesium levels – may be low with insulin resistance
  • Lipid panel – high triglycerides and LDL cholesterol, and low HDL cholesterol are a marker of insulin resistance and fatty liver
  • Metabolic profile (CMP) – for liver enzymes
  • Vitamin D – low levels increase the risk of insulin resistance and diabetes.

2. Disrupted gut microbiome

You have trillions of gut microbes, and due to antibiotics, birth control pills, sugar exposure, not enough fiber or probiotic-rich food, stress, and inflammation, it’s easy for inflammatory bacteria, yeast, viruses, and amoebas to overgrow. PCOS and diabetes correlate with disrupted gut microbiota.

How to test

You won’t get a thorough test from your GI doctor, as the conventional stool tests only use limited culturing methods. A genetic PCR test is far more useful to determine your microbial populations. The GI Map functional stool test is our go-to. You can order this kit on your own or through a practitioner who has an account with this lab.


3. Immune dysregulation and inflammation

Research shows that PCOS women have higher rates of autoimmunity. Inflammation drives the hormone imbalances found in PCOS, so it’s important to assess for causes of inflammation, which can be varied. It’s also important to screen for Hashimoto’s thyroid disease, which occurs more commonly in women with PCOS.

How to test

Inflammation is present in almost all cases of PCOS. By definition, chronic inflammation chronically activates the immune system. If you notice symptoms such as unexplained fatigue, headaches, joint and muscle aches, allergies, sinus congestion, skin rashes, or chronic skin conditions you may fall into this category. In addition, PCOS symptoms like excess abdominal fat and heavy painful periods actually cause more inflammation! Here are ways to test for inflammation:

  • High sensitivity C-reactive protein – levels above 3 indicated high levels of inflammation, below 1 is ideal.
  • Homocysteine – a metabolite of folate which is often elevated with inflammation. We aim for levels below 8. 
  • ESR (erythrocyte sedimentation rate) – a non-specific but often useful measure of inflammation. Anything above the lab range is considered an indicator of inflammation. 
  • CBC – look for very low or very high white blood cell counts with a shift of lymphocytes, eosinophils, or neutrophils (different types of white blood cells that fight infections). This may indicate a simmering, persistent infection.
  • The thyroid hormone reverse T3, if high, along with suboptimal levels of free T3, signifies inflammation that can cause hypothyroid symptoms. Calculate the ration here.
  • The Food Inflammation Test to find out if you are making delayed (IgG) antibodies against food proteins.
Autoimmune inflammation

If you have a family history of autoimmune disease, or you suspect you may have an autoimmune disease, these tests are a start: 

  • ANA titer (a general screening test for autoimmune risk) – greater than 1:40 is suggestive of autoimmunity.
  • Anti-TPO, Anti-TG and TSI Antibodies – screen for autoimmune thyroid disorders that are often correlated with PCOS.

Inflammation feeds insulin resistance through various mechanisms to impact hormone receptor signaling. It’s important to know the degree to which inflammation is involved, and to know your baseline to monitor your progress. If you find that you DO have inflammation present, you can start searching for the causes and treating them. 


4. Toxic burden and impaired detox

The concern here is both your exposures to chemicals in your environment that mess with your hormones, called endocrine disrupters, PLUS your ability to detox (metabolize) chemicals and hormones effectively. Some women with PCOS have genetic variations (SNPs) that make it harder to detox.

How to test
  • The 23 and me at-home saliva test will show you if you have SNPs that may interfere with detox. You can order this yourself and have a service or practitioner interpret it.
  • A CMP plus lipids blood test (above in the insulin resistance category) can shed light on your liver function.
  • A functional Organix test shows if you do have oxidative stress, and your need for detox nutrients such as glutathione.

It’s highly beneficial for all women with PCOS to switch to nontoxic body and beauty products, and household cleansers. Use the guides that the Environmental Working Group provides and don’t trust product marketing!


5. Post-pill PCOS

This refers to PCOS following the use of hormonal contraception. If you had normal periods prior to starting hormonal contraception and then developed signs of PCOS once you stopped it, you most likely fall into this camp. 

Note that the progestin in most birth control pills and hormonal IUDs can have pro-androgen effects. (A progestin refers to a synthetic, non-bioidentical version of progesterone, the hormone that your own body makes). This can increase your risk of insulin resistance, especially if you are genetically predisposed to PCOS. When you stop pro-androgen progestin (such as the newer 3rd and 4th generation birth control pills), you can experience a rebound release of excess androgens, as your SHBG drops. SHBG is a protein made by the liver that acts as a sponge to bind excess circulating hormones.

How to test
  • LH and FSH levels (pituitary hormones known as luteinizing hormone and follicle stimulating hormone) may be the only sign of post-pill PCOS. Typically the ratio of LH to FSH is greater than 2:1 or 3:1.  
  • Elevations in androgen levels are common. 
  • Insulin resistance is NOT typically found in post-pill PCOS. 

6 & 7: Adrenal and circadian rhythms imbalance

In 10-20% of cases, PCOS may be the result of an abnormal adrenal response to stress in the HPA (hypothalamic-pituitary-adrenal) axis. Your adrenal hormones can be at levels that are too high or too low, or your 24-hour rhythm may be off.

When you are exposed to chronic stressors, be they of an emotional, psychological or physiological nature, your adrenal glands produce cortisol, adrenaline, and adrenal sex hormones, such as DHEA and androstenedione. 

In most cases of adrenal PCOS, androgens that result from stress convert to testosterone. This has nothing to do with insulin resistance or abnormal ovarian hormone production. 

You must address your stress, your sleep, and your daily rhythms in order to reverse adrenal PCOS.  This is where significant lifestyle work is absolutely necessary to fix your PCOS. The PCOS Solution program guides you through the steps to do this, easily.

How to test
  • If your DHEA-S levels are elevated but serum testosterone is not, this may be adrenal PCOS.
  • DUTCH hormone testing by Precision Analytics is a comprehensive urine test to check for HPA axis abnormalities. You can order this test on your own, and a functional medicine practitioner can interpret it and treat your stress hormone imbalances.  

What’s next?

You may want to know what herbs or supplements you can take for each PCOS type. I can assist you with this in the Reclaim Your Hormones Program or in individual appointments. However herbs and supplements alone, just like prescription medications, may mask symptoms of PCOS, but they will not fix the root causes and reverse it for good.

Every single one of them requires “lifestyle medicine,” which consists of targeted adjustments in your eating, sleeping, movement, and other daily routines.

Now that you understand more about the underlying causes of PCOS, it is time to fix them! If you want to avoid medications and learn how to reverse the drivers that cause PCOS, check out the Reclaim Your Hormones Program to begin healing your PCOS. This 12-week experiential program addresses the primary drivers of PCOS (insulin and cortisol disruption) and balances all four phases of your menstrual cycle. Learn how to take control of your hormone health without the use of harsh drugs that only mask your symptoms. Fix your PCOS today! 

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