Maybe you’ve struggled with falling pregnant, or perhaps that extra weight simply won’t shift. Maybe your periods are few and far between and when they do come, they’re heavy and last for a week or more.  Whatever the case may be, a diagnosis of PCOS can feel frustrating, overwhelming and confusing. With such a vast array of different symptoms and a plethora of different treatment options out there, it can be a struggle to understand what will help you manage your symptoms and improve your health. This blog post breaks down the underlying mechanisms of PCOS, how it develops and how it affects your health. We will also look at each of the 4 major types of PCOS, including the underlying causes and how they manifest, to help give you a better understanding of what might be going on for you. We will also look at some treatment strategies naturopaths use to help combat this condition, including diet, nutritional supplements, and herbal medicines.

What is PCOS?

So, what is PCOS? The answer is complicated. Whilst PCOS (or polycystic ovary syndrome) is often discussed as if it is a singular condition, it is in fact a complex syndrome with many varying presentations and causes. Being a syndrome means PCOS isn’t one condition; the term ‘PCOS’ is simply the name given to a collection of similar symptomatic presentations. There are four major ‘types’ of PCOS, and each type has its own constellation of symptoms and underlying causes, but there is a considerable amount of overlap, too.

There are a wide range of symptoms associated with PCOS, but the most common symptoms include acne, missed periods (or a very long and irregular menstrual cycle), male-pattern hair growth on the face, chest and back (also known as hirsutism), overweight or obesity, acne, hair loss, and infertility. PCOS is a very common condition, affecting around 5-10% of women of reproductive age worldwide. PCOS is the most common hormonal disorder affecting women and one of the leading causes of infertility. Despite how common it is, there is still much that isn’t understood about how it manifests or its underlying causes. Making it even more complicated is that with some aspects of PCOS, such as insulin resistance, it is unclear whether it is a cause of PCOS, or whether insulin resistance is in fact a symptom. And whilst many symptoms such as hair loss and acne might seem superficial to some, the long term risks of PCOS are serious. The syndrome places women at higher risk of developing cardiovascular conditions in later life, including heart disease, high blood pressure and high cholesterol. It can also lead to an increased risk of developing type 2 diabetes and metabolic syndrome. The health risks of PCOS aren’t all physical, either. PCOS increases the risk of low self-esteem, eating disorders, depression, and anxiety, and leads to significantly reduced quality of life.

So, what exactly is going on in the body? Contrary to popular belief, PCOS and ovarian cysts are not the same condition, and, in fact, the “cysts” in PCOS aren’t really cysts at all. Confusing, isn’t it! The underlying mechanisms of PCOS are complicated, but primarily it is a disorder of disrupted ovarian function and hormone imbalance, with higher-than-normal levels of both oestrogen and androgens (“male” hormones like testosterone), and a higher ratio of androgens to oestrogen overall. Most PCOS cases also involve insulin resistance, too. This hormone imbalance is what disrupts the ovaries from functioning normally and stops ovulation from occurring.

In a normal menstrual cycle, hormones released by the pituitary gland in the brain trigger the ovary to produce multiple follicles (small, immature eggs). These follicles grow and secrete oestrogen, until day 7 of your cycle, when all but one of the follicles will be dissolved. The one remaining follicle will continue developing and maturing into an egg or “oocyte”, ready for ovulation on day 14 of the menstrual cycle. In PCOS, elevated insulin levels over-stimulate the ovaries and cause them to release higher than normal amounts of hormones. This leads to higher overall levels of both oestrogen and androgens in the body. Insulin then further exacerbates this hormonal imbalance, as insulin resistance in fat tissues converts oestrogen into male hormones inside fat cells. This means even higher androgen levels and an even bigger hormonal imbalance. Back in the ovaries, this hormonal imbalance causes too many follicles being produced each month, but their development is halted part way through the menstrual cycle before they can either mature into a functioning egg or be dissolved by the body. The follicles remain, partially matured, in the ovaries and appear as cyst-like formations on the ovaries during ultrasound. This is the reason for the “polycystic” portion of PCOS’s name. They are not really cysts but are, in fact, immature follicles that merely look like cysts. To make matters even more complicated, the presences of these “cysts” is also not diagnostic for PCOS and in fact, for many women, having lots of follicles in your ovaries can be normal, especially for younger women.

It’s important to remember that pain is not a symptom of PCOS. As discussed above, the “cysts” in PCOS are not actually cysts but immature follicles. If you are experiencing pain, this is not a part of PCOS and warrants investigation with your health care practitioner.

Diagnosis of PCOS

Diagnosis of PCOS will often have at least two of the following:

  • Evidence of multiple “cysts” (immature ovarian follicles) demonstrated on ultrasound
  • High androgens (e.g., testosterone or DHEAs) on blood tests
  • Physical signs and symptoms of PCOS, such as acne, hirsutism, and hair loss

It is important to note however that it is normal for some women to have a higher number of follicles, especially younger women and for this reason, relying purely on an ultrasound to confirm a PCOS diagnosis cannot be done.  Polycystic ovaries, whilst common in PCOS can simply be follicles or eggs on a normal ovary so other tests must be part of the diagnosis.

In addition to this, women can still have PCOS whilst also having ovaries that appear normal.

This is why naturopathically speaking, further tests might also be done to help determine some of the underlying causes and to help guide treatment plans. Tests might include an oral glucose tolerance test, and blood tests to assess levels of insulin, SHBG (sex hormone binding globulin), and the ratio of luteinising hormone and follicle stimulating hormone (to assess for ovulation and hormone balance).

Causes of PCOS

So, what really causes PCOS? It is often discussed as being a “lifestyle” disease (i.e., a condition that is caused by a sedentary lifestyle and poor diet), but the truth is more complicated than that, and framing it as a lifestyle condition can be upsetting for women who have spent years trying to manage symptoms through lifestyle habits without success. PCOS is generally the result of both genetic and environmental causes, and whilst lifestyle can certainly play a role, it is not the only underlying trigger to the development of PCOS. Other underlying causes include:

  • Genetics: Several genes have been identified by scientists as playing a role in the development of PCOS. Although it’s not clear yet how strongly they are linked, it is clear these genes at least predispose certain women to developing PCOS. Studies also show that it is at least partly inheritable, and often runs in families.
  • Inflammation: Chronic inflammation can work in much the same way as insulin resistance, triggering the ovaries to produce excess androgens.
  • The pill: Although post-pill PCOS is not “true” PCOS, coming off the pill can cause a temporary hormone imbalance that can lead to PCOS-type symptoms
  • Stress: Although not necessarily a cause of PCOS, studies do suggest that stress can worsen symptoms.

The 4 Types of PCOS

  • Insulin Resistant PCOS

Insulin-resistant PCOS is by far the most common type of PCOS, accounting for upwards of 80% of PCOS cases. This is the “classic” PCOS type with the underlying mechanisms as described above. Women with this type of PCOS often struggle with their weight and may be overweight or obese even despite efforts to lose weight. Reducing insulin resistance is the primary focus for treatment with this type of PCOS, through the use of dietary and lifestyle changes, and supplements such as inositol, magnesium, and even chromium.

  • Post-Pill PCOS

Post-pill PCOS is less common. Whilst many women may first discover they have PCOS when they come off the pill and develop symptoms, it doesn’t always mean that they have post-pill PCOS. Sadly, many women are unaware they even have PCOS until they come off the oral contraceptive pill in order to start having children. They may have been prescribed the pill in their early teens for “irregular periods” (which is normal in early adolescence), or to “treat” acne, and have stayed on the pill ever since. It is only when they come off the pill that their hormonal imbalance is identified. Its’s important to note, however, that the pill does not actually treat PCOS – it simply masks its symptoms. This is why symptoms return once you stop taking the pill.

It is only considered to be post-pill PCOS if your periods were well-established (you’d had them for 7 or more years) and regular before you went on the pill and are only irregular since stopping the pill. While uncommon, for some women, coming off the pill leads to a temporary rebound effect on hormones, leading to a hormonal imbalance that causes PCOS-type symptoms. Although it is temporary, it can be distressing, and naturopathic approaches can help to mitigate symptoms while hormone levels balance out again. Treatments such as the herbs liquorice and peony can be helpful in re-establishing normal ovarian function and hormone levels, as can supplements such as zinc.

  • Inflammatory PCOS

Chronic inflammation is something that is common in many women with PCOS. Chronic inflammation affects the ovaries by stimulating higher than normal androgen production, disrupting ovarian function and ovulation in much the same way as insulin resistance does. Women with inflammatory PCOS will generally have other symptoms associated with chronic inflammation that aren’t typical to PCOS, such as fatigue, joint pain, or chronic skin issuses like eczema. In inflammatory PCOS, it’s important to address the underlying cause (or causes) of the chronic inflammation. For some, this may be a food intolerance, commonly gluten or dairy. For others, it may be chronic gut issues or dysbiosis, or even histamine intolerance.

  • Adrenal PCOS

Adrenal PCOS is much less common than insulin-resistant PCOS, accounting for around 10% of cases. This is where adrenal dysfunction leads to high levels of cortisol (the “stress” hormone). High cortisol leads to increased levels of just one type of androgen – DHEAS – but doesn’t affect testosterone levels. This means that for women with adrenal PCOS, blood tests will show high DHEAS levels and normal levels of the other androgens, testosterone and androstenedione. For this type of PCOS, stress management and adrenal tonic herbs such as ashwagandha are the priority for treatment. As mentioned above, studies do suggest that stress in general plays a role in PCOS and therefore needs to be addressed even if your PCOS doesn’t fit the adrenal type.

Naturopathic Treatment Strategies for PCOS

The specific types and combinations of treatments that are used for PCOS vary depending on the type of PCOS. The following is an example of some of the common naturopathic treatment strategies used.

Eliminate Sugar

Sugar is often a significant driver of disease when it comes to PCOS. This is because sugar increases insulin requirements in the body, leading to the development and worsening of insulin resistance. All forms of refined and added sugar should be eliminated from the diet. This includes “hidden” sugars that can be found in supposedly healthy foods such as smoothies, commercial muesli and protein bars – see our blog post on hidden sugars in smoothies. Too much fruit can also be an issue, so it’s best to keep it to no more than 2 serves per day. Whilst eliminating sugar from the diet can be really tough, it’s worth it to get your insulin levels back on track. The good news is, once your insulin function improves, you’ll be able to enjoy the occasional sweet treat again.

 The Mediterranean Diet

Multiple studies have demonstrated the beneficial effects of the Mediterranean diet on PCOS, and it stands to good reason – this diet is low in sugar and pro-inflammatory foods and high in antioxidants, good quality proteins, and healthy fats – all the foods needed for managing PCOS symptoms.

16-8 Fasting

16/8 intermittent fasting (fasting for 16 hours per day and eating only during an 8-hour window each day) can help with PCOS symptoms by improving insulin sensitivity.

Exercise

Daily exercise is an absolute must when it comes to PCOS! Whatever your choice of exercise may be, aim to work up a good sweat each day and engage in at least 30 minutes of vigorous activity (but preferably aim for 60 minutes). Exercise helps to utilise glucose in the blood and improve insulin sensitivity. Over time, increased muscle mass from exercise can make our bodies even more efficient at maintaining our glucose and insulin levels even when we are at rest.

Supplements and Herbs

There are a whole host of supplements and herbs that are marketed towards PCOS management, but the truth is that the treatments that will suit you best will depend on your PCOS type and your individual symptom picture. Your naturopath will be able to guide you towards the best treatment plan for you, but the info below gives you some insight into how these treatments can help.

Liquorice and Peony

These two herbs are a common combination for treating PCOS. The two work synergistically together; liquorice helps balance hormone levels by improving the ovary’s ability to transform testosterone into oestrogen, while peony works to heal the ovaries.

Ashwagandha

Ashwagandha is an Ayurvedic herb that acts as an adrenal tonic, helping to improve adrenal function and improve cortisol function. This is particularly helpful for adrenal PCOS, or for instances where stress is making your symptoms worse.

Spearmint

Spearmint tea might be a surprising addition to the list, but several studies have found it to be effective. Drinking spearmint tea 3 times a day has been found to be effective at reducing androgen levels and has even been found to reduce hirsutism (chin and chest hair growth).

Supplements

Supplements are also frequently used, including:

  • Inositol: One of the most popular supplements on the market for PCOS, and for good reason. Multiple studies have shown that inositol can improve many aspects of PCOS, including lowering testosterone levels, improving insulin sensitivity, reducing acne, and improving fertility.
  • Zinc: helps improve insulin function but is also a great supplement for healthy ovary functioning and hormone health. Studies have shown it can help to reduce hair loss and hirsutism in people with PCOS.
  • Magnesium: a powerhouse mineral that is involved in hundreds of different processes in the body. Magnesium helps to make cells more sensitive to insulin but is also important for reducing high cortisol levels associated with adrenal dysfunction.
  • Omega 3 fatty acids: a vital nutrient that so many of us are lacking, omega 3s are needed for healthy cell walls and reducing inflammation. Omega 3 fatty acids are found in fatty fish such as salmon and tuna but can also be taken in supplement form if required.
    – Many omega 3 supplements on the market are poor quality, so I do recommend you look to your naturopath for a quality product, to make sure you’re getting benefit from your supplement. Vegan omega 3 supplements are also available and are usually algae derived.
  • Chromium: Another nutrient needed for healthy insulin function. Studies have shown chromium supplementation to improve menstrual cycles and ovarian health and reduce testosterone levels in people with PCOS.

References

Akdogan, M., Tamer, M. N., Cure, E., Cumhur Cure, M., Koroglu, B. K., & Delibas, N. (2007). Effect of spearmint (Mentha spicata Labiatae) teas on androgen levels in women with hirsutism. Phytotherapy Research, 21(5), 444/447.

Amr, N., & Abdel-Rahim, H. E. (2015). The effect of chromium supplementation on polycystic ovary syndrome in adolescents. Journal of Pediatric and Adolescent Gynecology, 28(2), 114–118.

Arentz, S., Abbott, J. A., Smith, C. A., & Bensoussan, A. (2014). Herbal medicine for the management of polycystic ovary syndrome (PCOS) and associated oligo/amenorrhoea and hyperandrogenism; A review of the laboratory evidence for effects with corroborative clinical findings. BMC Complementary and Alternative Medicine, 14.

Barrea, L., Arnone, A., Annunziata, G., Muscogiuri, G., Laudisio, D., Salzano, C., Pugliese, G., Colao, A., & Savastano, S. (2019). Adherence to the Mediterranean Diet, dietary patterns and body composition in women with polycystic ovary syndrome (PCOS). Nutrients, 11(10).

Briden, L. (2021). 4 types of PCOS (a flowchart). https://www.larabriden.com/4-types-of-pcos-a-flowchart/

Cuciureanu, M. D., & Vink, R. (2011). Magnesium and stress. In Magnesium in the central nervous system. University of Adelaide Press.

Damone, A. L., Joham, A. E., Loxton, D., Earnest, A., Teede, H. J., & Moran, L. J. (2018). Depression, anxiety and perceived stress in women with and without PCOS: A community-based study. Psychological Medicine, 49(9).

Fazelian, S., Rouhani, M. H., Bank, S. S., & Amani, R. (2017). Chromium supplementation and polycystic ovary syndrome: A systematic review and meta-analysis. Journal of Trace Elements in Medicine and Biology, 42, 92–96.

Grant, P. (2010). Spearmint herbal tea has significant anti-androgen effects in polycystic ovarian syndrome: A randomized controlled trial. Phytotherapy Research, 24(2), 168–188.

Jamilian, M., Foroozanfard, F., Bahmani, F., Talaee, R., Monavari, M., & Asemi, Z. (2016). Effects of zinc supplementation on endocrine outcomes in women with polycystic ovary syndrome: A randomized, double-blind, placebo-controlled trial. Biological Trace Elements Research, 170(2), 271–278.

Khan, M. J., Ullah, A., & Basit, S. (2019). Genetic basis of polycystic ovary syndrome (PCOS): Current perspectives. Applied Clinical Genetics, 12, 249–260.

Merviel, P., James, P., Bouee, S., Le Guillou, M., Rince, C., Nachtergaele, C., & Kerlan, V. (2021). Impact of myo-inositol treatment in women with polycystic ovary syndrome in assisted reproductive technologies. Reproductive Health, 18.

Sadinpour, A., Seyedi, Z. S., Arabdolatabadi, A., Razavi, Y., & Ajdary, M. (2020). The synergistic effect of Paeonia spp and Glycyrrhiza glabra on polycystic ovary induced in mice. Pakistan Journal of Pharmaceutical Sciences, 33(4), 1665–1670.

Unfer, V., Facchinetti, F., Orru, B., Giordani, B., & Nestler, J. (2017). Myo-inositol effects in women with PCOS: A meta-analysis of randomized controlled trials. Endocrine Connections, 6(8), 647–658.

Wekker, V., van Dammen, L., Koning, A., Heida, K. Y., Painter, R. C., Limpens, J., Laven, J. S. E., Roesters van Lennep, J. E., Roseboom, T. J., & Hoek, A. (2020). Long-term cardiometabolic disease risk in women with PCOS: A systematic review and meta-analysis. Human Reproduction Update, 26(6), 942–960.

Yang, K., Zeng, L., Bao, T., & Ge, J. (2018). Effectiveness of omega-3 fatty acid for polycystic ovary syndrome: A systematic review and meta-analysis. Reproductive Biology and Endocrinology, 16.

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