What is PCOS?
Polycystic Ovary Syndrome (PCOS) is an endocrine (hormone-related) condition affecting approximately 2 in 10 women of reproductive age. Less than a third of PCOS sufferers are overweight.
If you have PCOS, it is likely you will be affected by
Oligomenorrhoea (fewer periods)/ anovulation (cycles where ovulation has not occurred)
Hormone imbalance leading to hirsutism (hair in places such as the lip, back, umbilicus and nipples); there may also be problems with insulin resistance, raised inflammatory markers and blood lipids
Difficulty conceiving if you are having anovulatory cycles (this is common but does not happen to everyone with PCOS)
What causes PCOS?
It is thought to involve a hormone imbalance with excess testosterone, which may also occur as a result of action of insulin (reduced insulin sensitivity in peripheral tissues which in turn encourages the ovaries to produce androgens). We also know that there is a genetic disposition to PCOS, as it is likely to run in families, but we also know we can influence PCOS with lifestyle change. As we often say, ‘the genes load the gun but the environment pulls the trigger’.
Our recent scientific understanding expands beyond this to talk about PCOS as a multi-system disorder with low-grade systemic inflammation (with potential microbiome involvement) and cardiometabolic components.
One of the key problems in PCOS is predisposition to excess ovarian androgen secretion. High androgens also affect insulin sensitivity and secretion, but independent genetic and lifestyle factors also have a role. Once established, high insulin levels further worsen ovarian androgen production and contribute to androgen-dependent hirsutism (excess hair) by suppression of liver secretion of SHBG (a hormone binding protein), which increases free testosterone. When present, insulin resistance is the main factor that increases the risk of type 2 diabetes mellitus in women with PCOS.
What are the risks of PCOS?
Problems with fertility, gestational diabetes (diabetes in pregnancy), type 2 diabetes, insulin resistance, metabolic syndrome (abnormal lipid profile, high blood pressure) with resulting increased risk of cardiovascular disease, overweight/obesity, endometrial hyperplasia (changes in uterine cell lining) and in the long term, increased risk of endometrial (uterine) cancer due to loss of endometrial protection provided by progesterone released during regular ovulation.
How is PCOS diagnosed?
Diagnosis is based on the “Rotterdam criteria” whereby women have got to have 2 out of the 3 criteria described below:
1. Ultrasound scan : greater than 12 follicles noted around the ovary approximately 2-9mm in size (sometimes described as a string of pearl appearance).
2. No ovulation or reduced ovulation (tested by performing a mid luteal progesterone level via a blood test).
3. Hyperandrogenism (excess hormones for example high testosterone or lute using hormone levels as well as hirsutism ). 1/3 of women may have normal hormone levels, this is why a thorough and personalised assessment is important.
How can I help myself and my symptoms with PCOS ?
At the Synthesis Clinic we advocate a personalised Lifestyle Medicine approach. Lifestyle medicine should be the first line therapy and aims to reduce insulin resistance and restore hormone balance to enable natural and regular cycles to occur, aid weight loss if needed and reduce future health risks. By improving insulin resistance, often just a 3% weight loss can also see cycles return to regular and enable ovulation to occur (of course, we also know that PCOS happens in women who are not overweight).
Lifestyle advice includes:
1. Wholefood-based plant-focused diet - reducing/avoiding alcohol and highly refined foods packed with sugar and saturated fat and opting for a low glycaemic load diet balanced in protein, healthy fats and complex carbohydrates. Including plenty of colourful vegetables, some low sugar fruit (e.g. berries) and herbs and spices increases micronutrient and antioxidant intake from plant foods and provides fibre, which helps with blood sugar regulation and promotes a healthier gut microbiome.
2. Exercise - any exercise or movement is great but a focus on strength via weight or body weight resistance training. High intensity interval training (HIIT) can also help improve insulin resistance but may not be appropriate for everyone.
3. Good quality sleep of 7-9 hours per night helps us not only rest and restore but can help manage food cravings and support better hormone balance, including insulin resistance.
4. Stress management - consider mindfulness, yoga and outdoor movement.
What else will my GP or gynaecologist offer me?
Given the increased risk of endometrial hyperplasia and cancers long-term in women not having regular cycles, your doctor may offer you the progesterone only pill (mini pill), combined pill depending on your BMI, the Mirena IUS or inducing a period at least 4 times per year. This will serve to reduce your risk of endometrial problems in future. Alternatively, if you are overweight, with just 3% weight loss you can regulate your own cycles and avoid these risks. Instituting other lifestyle changes and targeted supplementation may also help restore regular ovulation.
Your doctor will likely offer you a fasting blood sugar test to evaluate your insulin resistance and risk of type 2 diabetes. If you are pregnant, you would have an oral glucose tolerance test at week 28 in your pregnancy to ensure you haven’t got gestational diabetes (diabetes in pregnancy). They are likely to advise annual testing of diabetes thereafter.
How can changes in my diet help my PCOS?
As just one example, fibre prevents spikes in blood sugar, aids sustained weight loss (long term) and helps reduce insulin resistance. Good fibre intake increases serum binding globulin (SHBG) which mops up excess androgen hormones known to be a problem in PCOS.
Increasing the amount of vegetables in your diet with some low sugar fruit will help you get increase your fibre. The best fruits to consume are berries, pomegranate and temperate fruit (e.g. apples) compared to higher sugar tropical fruit or dried fruit. Nutrient-rich leafy greens (spinach, kale, broccoli, pak choy) as well as avocados (for both healthy fats and fibre) are good food choices but we love aiming for the whole rainbow (download the rainbow phytonutrient guide here). Just 2-3 tablespoons of milled flaxseed daily can help provide not only fibre and healthy omega-3 fats but has also been shown to change insulin resistance, lipid and inflammation levels in women with PCOS. Keep milled flax in the fridge after opening to protect the healthy fats from oxidation.
Overall, we can aim to plan meals to be based around sufficient protein, healthy fats and low GL complex carbohydrates, e.g. legumes and whole grains instead of simple carbohydrates and refined sugars or artificial sweeteners.
How can precision (personalised) health approaches at Synthesis Clinic help my PCOS journey?
At Synthesis we do not believe a ‘one size fits all’ approach. If general lifestyle measures do not help your symptoms, we advocate a tailored assessment and management plan to suit your needs to fit in with your lifestyle. Looking at specific hormone, metabolic and genetic aspects can help lead to a better understanding of individual root cause and open the possibility of targeted treatment plans. Our multidisciplinary team offers expertise on all levels to help you achieve your goals whether that is healthy weight, struggles with infertility, hormone imbalance or whether you are looking to future proof your health.
About the author
Dr Amy Shacaluga is a Consultant Obstetrician and Gynaecologist, Lifestyle Medicine Physician and Functional Medicine Practitioner, with over 14 years’ experience in women’s health. Dr Amy provides 1:1 consultations at Synthesis Clinic, working closely with our multidisciplinary team at Synthesis, including joint programmes with our nutrition professionals as needed.
References
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Lim SS, Hutchison SK, Van Ryswyk E, Norman RJ, Teede HJ, Moran LJ. Lifestyle changes in women with polycystic ovary syndrome. Cochrane Database Syst Rev. 2019 Mar 28;3(3):CD007506. doi: 10.1002/14651858.CD007506.pub4. PMID: 30921477; PMCID: PMC6438659.
Patel S. Polycystic ovary syndrome (PCOS), an inflammatory, systemic, lifestyle endocrinopathy. J Steroid Biochem Mol Biol. 2018 Sep;182:27-36. doi: 10.1016/j.jsbmb.2018.04.008. Epub 2018 Apr 17. PMID: 29678491.