The polycystic ovarian syndrome, in short PCOS, is the most common cause of infertility, affecting 1 in 10 women. It is mindblowing to think doctors have no real solution for such a common condition. Usually, you will go between the contraceptive pill if you don’t want kids and fertility treatments if you want them.
Some might also suggest metformin, a diabetic drug, that causes a horrible amount of side effects. Finally, there are anti-androgenic medications, such as spironolactone, that reduce the side effects of the syndrome, such as hirsutism and hair loss. The downside is that they are very hard to quit and the symptoms will come back with a vengeance when you finally do. The bigger problem is that none of the meds addresses the core problem, they just put a temporary bandaid over the symptoms.
The first step in figuring out the correct approach towards your PCOS is to figure out what is causing it and if you actually have it. Yes, you read that right. Nowadays, many doctors are quick to diagnose PCOS, but often times that problem is actually different. Before I dwell into the topic further, let me say that this post is partly inspired by the amazing dr. Lara Briden and her book, Period Repair Manual. The other part is personal, as PCOS is a diagnosis I myself have received.
Do you really have PCOS?
You’ve checked the signs of a possible hormone imbalance and think you have some sort of problem. If you go to your doctor with irregular or missing periods, the first thing they’ll probably do is an ultrasound. Now, if you haven’t had your period in a while, chances are the ultrasound will reveal “small cysts” on your ovaries. Doctors are quick to call these polycystic ovaries. However, as dr. Lara Briden discusses in her book, this is a normal thing if you haven’t ovulated in a while. The aspect is given by the follicles that form, as they should in your follicular phase. In a normal cycle, one follicle becomes dominant, realising the egg and causing the other follicles to die. If you do not ovulate, those follicles remain stagnant giving your ovaries a polycystic aspect. Which is why PCOS should NEVER be diagnosed just based on an ultrasound.
Blood work is essential!
The next step towards a diagnosis is to run full hormonal blood work. This will include tests like FSH, LH, estradiol, prolactin, SHBG, testosterone (free and total), androstenedione, DHEA-S, and a full thyroid panel (NOT just TSH). In order for a PCOS diagnosis to be confirmed the Rotterdam criteria says at least two of the following three must be met:
- Polycystic ovaries on ultrasound
- Hyperandrogenism – either through clinical manifestations (excess hair, hirsutism, etc) or hyperandrogenemia (high androgens on a blood test)
- Ovulatory dysfunction (anovulation or oligomenorrhea).
With regards to clinical manifestations of hyperandrogenism – you should know that 3-4 hairs on your belly button or around your nipples are not necessarily a cause for concern and are normal to appear when you are a teenager. At that age, as your hormones figure themselves out, there is a normal temporary androgen surge which can cause a bit of hair growth. So unless you meet – truly meet – at least three of those criteria, you DO NOT have PCOS. There are also those who believe all three should be met because if you meet 1 & 3 of that list, you can actually not rule out thyroid issues or hypothalamic amenorrhea. High androgens are usually a must for a proper PCOS diagnosis.
Types of PCOS
This is by far the most common type of PCOS. It usually comes with excess weight, difficulty to lose weight and high testosterone. The high testosterone, in turn, will give symptoms like hirsutism, hair loss, and anovulation. Insulin resistance is not tested by testing fasting glucose. You can be insulin resistance and have normal blood sugar levels. This is because the condition is a precursor to diabetes. The risks associated with this condition include heart attack, diabetes, cancer, and for those who do not ovulate, osteoporosis. The condition can also come with high LH to FSH ratio, which in turn makes the ovaries produces androgens.
The most common treatment for insulin-resistant PCOS is metformin. A more natural alternative, proven to be extremely efficient in restoring ovulation is inositol. This is probably the most researched natural alternative for managing PCOS and has amazing benefits such as:
- lowering testosterone
- increasing SHBG (sex hormone binding globulin)
- lowering LH (luteinizing hormone)
- weight loss
You can read more about inositol and its benefits in this article.
I’m skinny. Should I test for insulin resistance?
The short answer is yes. It is possible to be insulin resistant and be skinny. It is rare, but sadly, not unseen. Genetic factors can put you at risk, so if you know you have someone with type 2 diabetes in your family and have PCOS-like symptoms, definitely check! You can read more about it here.
Inflammation is a component with all types of PCOS, but here this will be the main issue. This is the type where you do not have insulin resistance, have a high LH:FSH ratio, and you might have some high androgens, probably testosterone. DHEA-S, however, should be normal. Furthermore, you will have some symptoms of inflammation: achy joints, unexplained fatigue, IBS, allergies, food intolerances. It can be more difficult and slow to treat. The first step is to remove all foods that can cause inflammation – gluten, sugar, cow’s milk (casein more specifically), and alcohol. Some supplements can help too, such as berberine and liquorice. Stay away from vitex if you have high LH because it works by increasing LH and you do not need more of that. Progress is, sadly, slow, as it can take up to 6-9 months to heal.
The third type of PCOS is the adrenal type. This happens when you are not insulin resistant, have normal ovarian androgens (testosterone and androstenedione) but high adrenal androgen, namely, DHEA-S. Adrenal PCOS makes up a total of 30% of PCOS cases. You’d think it should be more known, but sadly, it isn’t. This is usually derived from chronic stress and excess cortisol, and sadly, it can be even slower to heal than inflammatory PCOS. Lifestyle and reducing all forms of stress as much as possible plays a huge role. Supplements can help, but there is no one size fits all and no magic pill. The contraceptive pill, however, can mask your symptoms and help your body get even sicker because you won’t see the signs. A really good article discussing adrenal PCOS can be found here. And if you want to read more about this type of PCOS and natural ways to treat it, check out this article.
The fourth type of PCOS is that one that happens once you stop using hormonal contraceptives. Its main characteristic is that periods were perfectly normal before the pill. I wrote more about it in a separate article, so head over there to read more.
Have you been diagnosed with PCOS? What was it based on? What are you doing to manage the symptoms? Let us know in the comments and help other women feel less lonely in their journey with PCOS.
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