PCOS: Beyond What Your Doctor Tells You

by Dr. Laura Paris and Dr. Anita Sadaty

Wonder if you have PCOS? Take the quiz:

On a regular basis, we 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 drivers of PCOS. By knowing the drivers, we can reduce and possibly reverse the impact of this condition.

Here we discuss the most common drivers 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.

Meet the most common drivers of PCOS

If you have a PCOS diagnosis, you likely have the primary driver, which is insulin resistance, along with one or more secondary drivers. It is important for you to address each one to improve your health and reduce or reverse your symptoms and associated risks. The primary driver is insulin resistance and blood sugar dysregulation, which affects most women with PCOS. The secondary PCOS drivers include:

  1. A disrupted gut microbiome with inflammatory microflora
  2. Immune dysregulation with inflammation and/or auto-immune cofactors
  3. Toxic burden environmental exposures, combined with genetic snips that impair detox
  4. Adrenal hormone imbalance with elevated DHEA and/or cortisol

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

THE PRIMARY DRIVER: 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. For example, high insulin can result in type two diabetes, cardiovascular disease, high blood pressure, osteoporosis, or dementia. It can also contribute to high estrogen levels and increased cancer risk. This is why it’s important to heal PCOS beyond solving the immediate hormone symptoms such as weight gain, acne, male-pattern hair growth, infrequent periods, and infertility. The majority of women with PCOS are on the insulin resistance spectrum.

How to test

  • Fasting insulin (should be less than 10, ideal is around 5)
  • Fasting glucose (should be less than 99, ideal is 75-85)
  • Hemoglobin A1C (should be less than 5.4, 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
  • Lipid panel – high triglycerides and LDL cholesterol, and low HDL cholesterol are a marker of insulin resistance
  • Metabolic profile (CMP) – for liver and kidney markers
  • Vitamin D – low levels increase the risk of insulin resistance and diabetes
  • Omega check – low omega-3 levels are associated with insulin resistance and type two diabetes

Some women with PCOS are on the road to insulin resistance, however, it may not show up yet on most of these lab markers. It can take years or decades for all these markers to become out of range. Dysregulated sugar and insulin first show up on the two-hour tolerance test, so this may be the single most important test to determine whether or not you’re on the insulin-resistant spectrum. The sooner you catch it, the easier it is to reverse.

SECONDARY DRIVER #1: 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. A disrupted gut microbiota is correlated with PCOS and can affect metabolism, weight, appetite, digestion, elimination, and nutrient and hormone levels.

How to test

You won’t get a thorough test from your GI doctor, as 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 even order this kit on your own or through an integrative/functional clinician.

SECONDARY DRIVER #2: Immune dysregulation

Research shows that PCOS women have higher rates of inflammation and 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 autoimmune thyroid disease, which occurs more commonly in women with PCOS.

How to test

By definition, chronic inflammation 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 weight 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, and below 1 is ideal.
  • Homocysteine – a metabolite of folate which is often elevated with inflammation. Aim for 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 ratio here.
  • In addition to the GI Map, you can test for inflammatory food reactions with the Food Inflammation Test.

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.

SECONDARY DRIVER #3:Toxic burden

The concern here is both your exposure to endocrine-disruptive chemicals in your environment that contribute to PCOS hormone imbalance, PLUS your ability to detox (metabolize) chemicals and hormones effectively. Some women with PCOS have genetic variations (SNPs) that make it harder to detox. Both of these situations can result in excessive estrogen, which can contribute to cancer risks, inflammation, weight gain, and heavy painful periods.

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 comprehensive metabolic panel can shed light on your liver function. In addition, you can test the liver enzyme called GGT which is an indicator of toxic burden.
  • The Dutch Complete Hormone test is invaluable because it measures how you metabolize (detox) estrogen through phase 1 and 2 of liver detoxification. In addition, it reveals if you have oxidative stress, which is another marker of toxicity, plus your levels of detox nutrients such as B vitamins and glutathione

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

SECONDARY DRIVER #4: Adrenal hormone 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. When you are exposed to chronic stressors, be they of an emotional, psychological or physiological nature, your adrenal glands produce cortisol, adrenaline, and the androgen hormones DHEA and androstenedione. 

In most cases of adrenal-driven 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. If you know you need help regulating your adrenals, we designed the Fix Your Adrenals course specifically for this purpose.

How to test

  • If your DHEA-S levels are elevated but serum testosterone is not, this may be adrenal PCOS.
  • The DUTCH Complete Hormone test, mentioned in the toxicity section above, also checks for HPA axis abnormalities.

What’s next?

You may want to know what herbs or supplements you can take for each PCOS driver. These can help, 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 driver 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 drivers of PCOS, it is time to fix them! If you want to avoid medications and reverse your PCOS symptoms and lab markers, as well as improve your health for the long term, check out our PCOS Solution program. This 6-week experiential program walks you through how to heal all five drivers of PCOS and gives you the lowdown on the supplements that are right for your particular manifestation of PCOS. Learn how to take control of your hormone health without the use of harsh drugs that only mask your symptoms. Fix your PCOS today! 

Dr Anita Sadaty, Dr Laura Paris, functional medicine, PCOS SOLUTION, acupuncture, pcos

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