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PCOS, Your Fertility & What To Do About It

Oct 26, 2020

 By Kasey Willson


Mentioned throughout episode:

>> The Glutathione product I use for smoothing fine lines & wrinkles, is found here 

>> The preconception health guide, Glowing Mumma 


Are you facing fertility challenges? Maybe you’re not trying for a baby right now but experiencing cycle irregularities, skin issues, weight challenges and/ or unwanted hair growth symptoms? If you’ve done a quick search on the interweb, it’s likely you’ve been lead to Polycystic Ovarian Syndrome (PCOS). Or perhaps you've been given a diagnosis of PCOS by your GP, but you really don't know where to go from here?

Chances are, if you don’t have PCOS, you know someone who does. So this episode is dedicated to giving you an understanding of what PCOS is, the signs, symptoms and causes, consequences of the syndrome. Plus how you can get a diagnosis and I give you some simple steps so you can seek the guidance you need to support your hormones, cycle and body back to balance. 

What is PCOS?

Polycystic ovarian syndrome (PCOS) is a hormone disorder with increasing prevalence and now affecting 1 in 5 Australian women of a childbearing age and 1 in 7 worldwide.1 It is one of the leading drivers for female infertility and alarmingly 71% of women with PCOS remain undiagnosed.2

Having PCOS means that your ovaries aren’t getting the right hormone signals from the pituitary gland in your brain, resulting in failure to ovulate regularly and an overall increased level of androgen production. It's like the brain is calling the ovaries, but there is no phone signal.

The heightened androgen production is contributed by an elevated Luteinising Hormone (LH) to Follicle Stimulating hormone (FSH) ratio. This LH is produced from your pituitary gland, in the brain. This is also often an increased production of insulin from your pancreas. This incidence of abnormal insulin activity associated with PCOS further contributes to androgenic activity and the symptoms of PCOS.3

How Androgens Play A Role In PCOS

Androgens are a group of hormones that are made in your ovaries and adrenal glands, including DHEA Sulphate (DHEAS), DHEA, androstenedione and testosterone.

Your adrenals produce all of your body’s DHEA Sulphate (DHEA-S), 80% of DHEA levels, 50% of androstenedione and 25% of testosterone. High adrenocorticotropic hormone (ACTH), secreted from your pituitary gland in response to stress contributes to this adrenal androgen production. The health of your adrenal glands is therefore paramount for balanced hormones.

These hormone imbalances involved with PCOS prevent a normal (short term) LH surge required for ovulation each month. Instead its often elevated the whole time. When ovulation is suppressed, or happening irregularly, periods are less frequent (if happening at all) and the hormonal imbalances can (but not in all cases), contribute to growth of benign masses on your ovaries, called ovarian cysts.

Constant increased luteinising hormone (LH), from your pituitary gland, as seen in PCOS is another contributing factor for excess androgen production & so the PCOS cycle continues.  

Post Pill PCOS

Coming off of the oral contraceptive pill could also contribute to hormone imbalance in your body, through impacting the communication between your brain and your ovaries.

While taking the OCP, the communication between your hypothalamus and pituitary glands in your brain with your ovaries is shut down, preventing ovulation, regular periods and your ability to conceive. In most women, this communication will return soon after stopping the OCP, ovulation will resume and if no conception takes place, a period is experienced between 9-16 days later.

In some women however, this communication remains suppressed for months and in some cases, years after ceasing the OCP. This shuts down ovulation long term and therefore impacts fertility. If this is happening, further diagnosis is needed to determine why your brain still can’t get a signal when trying to communicate with your ovaries, and vice versa.  

Firstly, it could be due to under-eating, overexercise and high stress levels. This is called Hypothalamic amenorrhea and is indicated with suppressed FSH and LH on a blood test, with other levels being at normal levels.

The second subtype is solely caused by being on and stopping the OCP. In this case, periods were regular prior to starting the birth control pill but don’t return after stopping the pill. Symptoms of PCOS such as heightened LH:FSH ratio, acne and possibly cysts on your ovaries also often present.

Thirdly, your post pill PCOS symptoms could be from “True PCOS” where you already had irregular or non-existent periods prior to starting the synthetic hormones, and often along with symptoms of insulin resistance, hirsutism, acne and ovarian cysts. Let's explore this type and some causes.

Other Causes of PCOS

Early menarche, a family history of PCOS, together with a pre-existing irregular cycle can increase your chance of developing PCOS. Other contributing factors include:

Obesity, Insulin resistance & Leptin Resistance

A staggering 40-80% of women with PCOS will show have insulin resistance.4 When your blood sugar levels are erratic over the day, this creates stress on your insulin producing organ, the pancreas. This happens when your diet choices are high in sugars, the glucose levels in your bloodstream will soar. This initial high is followed by a state of low levels and fluctuation between high and low throughout the day which can lead to headaches, dizziness, mood swings, shakes, behavioural issues, poor concentration, fatigue, excessive sweating and waking throughout the night.

A dramatic increase in blood sugar levels will trigger your trusty organ, the pancreas, to produce insulin. Insulin carries glucose from your blood stream into your cells, where you can happily use it for energy production.

High insulin surges (due to high glucose), over time contributes to a state of insulin resistance. Your body no longer responds to initial insulin spikes and instead requires higher and higher amounts of glucose to recognise its presence and utilise it for blood glucose transport.

The glucose struggles to enter your cells and as a result cannot be used for energy, but instead is stored as fat. When the liver is exposed to high levels of glucose and/ or fructose, fat producing enzymes are activated, contributing long term to type 2 diabetes, hypertension and cardiovascular disease.5, 6 Taking into consideration the stress blood sugar imbalances place on your adrenal glands, prolonged high glucose levels and insulin resistance are also an underlying driver for thyroid, adrenal and sex hormone imbalance and the resulting PCOS.7

The condition up regulates an enzyme called 17, 20-Lyase, which results in excessive testosterone production from the ovaries and contributes to the condition of PCOS. Heightened insulin also reduces circulating sex hormone binding globulin (SHBG) which increases the availability of your body to use and respond to testosterone.1 It may also help the production of androgens from the ovaries and adrenals.8

Insulin resistance also has the potential to increase oestrogen (testosterone is still higher proportionally) and this increased oestrogen suppresses FSH, contributing heading to a state of infertility.

Interestingly in men, insulin resistance encourages an enzyme called aromatase, which converts testosterone into oestrogen. Higher oestrogen levels in men contributes to loss of head hair.

In Leptin resistance, the message from your fat cells to the brain is no longer sensitive to your leptin signal, leading to constant hunger levels. Over time, insulin and leptin resistance can contribute to PCOS. 

Some causes of insulin resistance include: Drugs (corticosteroids and thiazide diuretics), ageing, diet (high glucose and fructose particularly), lack of exercises, smoking, central obesity and interestingly and a family history of type 2 diabetes. Hyperandrogenism (high androgen levels) is also a cause and effect of insulin resistance.

Obesity

Obese women with PCOS have more pronounced menstrual cycle abnormalities and problems with fertility, as well as more severe symptoms of excess androgens such as hirsutism and acne, than normal weight PCOS women.” Ruth Trickey explains in her text Women, Hormone & The Menstrual Cycle.

Central obesity is common in PCOS and has shown to be a factor of fertility issues.9 This central fat distribution contributes to disturbed ovarian function and is associated with higher levels of fasting insulin, LH, oestrone and androstenedione than if you have PCOS lacking central fat distribution. Elevated leptin levels are also common with this obesity, where it decreases aromatase activity in women (an enzyme allowing the conversion of androgens into oestrogens).10

Stress

In response to stress, the hypothalamus in your brain, sends a message and stimulates the pituitary gland to produce ACTH (Adrenocorticotropic Hormone), which stimulates the adrenals to produce DHEA, DHEAS and androstenidione, along with cortisol, adrenaline and noreadrenaline. These hormones are then converted into testosterone in the peripheral tissues of the body, contributing to higher androgens levels and the symptoms of PCOS. The more chronic the stress, the higher the production of DHEA and testosterone levels.

Usually the adrenal hormone cortisol has a feedback loop when produced at high levels to tell the pituitary gland to slow the production of ACTH. Unfortunately, androgens don’t send this same message and if stress continues, levels of DHEA, androstenedione and testosterone continue to rise, compounding the symptoms of PCOS. This can happen even with normal insulin sensitivity and in the absence of ovarian cysts, indicating that stress alone is a powerful driver of hormonal imbalance.

Included in the contributors of PCOS is the stress of over-exercise. If you are working out daily and pushing your body to the limits but struggling with hormonal imbalance symptoms such as irregular cycles or hirsutism, listen to your body. It may be time to change your exercise routine. 

Other sources of stress to explore, may include:

  • Work
  • Financial
  • Relationships
  • Travel
  • Alcohol
  • Caffeine intake eg. over one cup of coffee per day
  • Processed foods (trans fats, sugar, artificial sweeteners, additives, preservatives)
  • Electromagnetic (wi-fi, phones, i-pad, laptop and computer screens)
  • Toxic exposures
  • Poor sleep quantity and quality

Hypothyroidism

In the state of an under active thyroid, phase II elimination of sex hormones in your liver, including testosterone, is slowed and a build-up effect can occur, compounding the PCOS cycle.11

Inflammation & Gut Health

Inflammation and a slow moving bowel can impact your gut health and encourage beta-glucuronidase enzyme activity.12 Just as it does with oestrogen, beta-glucuronidase contributes to a recycling effect of your detoxified testosterone, leading to higher overall levels in your body.

Toxins

Studies have shown higher levels of toxins including per fluorinated compounds, bisphenol A (BPA), pesticides and polycyclic aromatic hydrocarbons showing in women with PCOS, over control groups. Yet this as a direct cause is still not confirmed. BPA exposure can contribute to increased androgen and insulin levels, which has an association with PCOS development. When the time comes for you to have a baby, note that a mother’s exposure to BPA during pregnancy has been linked to PCOS development in female children.13,14,15

Luteal Phase Defect 

The luteal phase of a cycle can vary from woman to woman but is generally the same time frame during each of your cycles. This can vary from 9-16 days, but must be at least 9 days (optimally > 12) for the cycle to be considered fertile. A short luteal phase indicates an issue at ovulation leading to inadequate progesterone production or an early drop in progesterone levels. As progesterone is the hormone required to ripen and preserve the tissue and blood of your uterus, a deficiency causes premature shedding of the uterus lining and results in an infertile cycle called a luteal phase defect.

The absence of a LH surge required to bring on ovulation, can also cause a luteal phase defect. This is a common occurrence in the condition of PCOS.

Let’s explore the signs and symptoms of PCOS

It is important to firstly note that not all cases of PCOS include polycystic ovaries, which show up on an internal (transvaginal) ultrasound. These cysts that cluster on the surface of the ovaries, are in reality immature follicles around 5—10mm in size that didn’t complete the full process of ripening (folliculogenesis), which may be due to the irregularity or suppression of ovulation.

Women with normal cycles can actually show up with a cluster of cysts on their ovaries without having polycystic ovarian syndrome and a woman can show a clear ultrasound scan, but experience an erratic menstruation cycle and have PCOS. Confusing, I know.

So it is therefore important to look at all the other important diagnostic factors for the condition of PCOS, which include: 

  • High androgen levels through blood tests (hyperandrogenism)
  • Growth of body and facial hair and male pattern baldness (thinning of head hair). Facial and body hair growth including the chest, abdomen and upper thighs occurs in 60-70% of women with PCOS. This is referred to as hirsutism. High androgen levels are associated with hirsutism in 70% of women who experience male-pattern hair growth.17
  • Absence of ovulation
  • Together with an increase in androgen levels, PCOS is often also driven by oestrogen dominance and deficient progesterone levels.

The full list of PCOS signs & symptoms, include:

Clinical Signs

  • Oily skin and acne
  • Irregular or absent menstrual cycles. Less than 8 cycles per year is referred to oligomenorrhoea and amenorrhoea is an absence of a period for 3 months of more- both of which are signs of PCOS. Some women with PCOS also experience erratic and heavy bleeding.

Stimulation of the endometrium by oestrogen-usually oestrone- in combination with the absence of ovulation and therefore progesterone, can lead to inadequate transformation of the endometrium.” Ruth Trickey.

  • Fertility challenges, driven by the different causes of PCOS (post pill, stress, insulin resistance and obesity, for example)
  • Reoccurring miscarriages and pregnancy health challenges such as hypertention, gestational diabetes and pre-eclampsia

Endocrine Signs

  • Elevated androgens
  • Elevated luteinising hormone (LH)
  • Heightened oestrogen (Oestrone)
  • High prolactin
  • Other symptoms of progesterone deficiency, as the lack of ovulation prevents progesterone levels from peaking

Metabolic Signs

  • Insulin resistance occurs in 50-70% of women with PCOS16 which is an underlying cause of the reproductive and metabolic disorders and effect of obesity. Th higher levels of insulin seen in insulin resistance, decreases sex hormone binding globulin, therefore increasing availability of testosterone.17 The high level of circulating androgens causes a release of inflammation producing cytokines, TNF-alpha and IL-6 into the bloodstream and overtime they contribute to insulin resistance.
  • Impaired glucose tolerance and type 2 diabetes mellitus18
  • Difficulty shifting weight. 30-75% of women with PCOS are also obese.19 It is important to note however, that women who are a healthy weight range can still develop PCOS

This leads me to the Complications Of PCOS.

Complications Of PCOS

Living with the high insulin, luteinising hormone, androgen levels and weight challenges of PCOS, increases the chance of developing health conditions. These include:19, 20,21,22

  • Impaired glucose tolerance and Type 2 diabetes. The prevalence is much higher amongst women with PCOS23 and develops more so with obesity and alongside cases of insulin resistance.
  • Midsection weight gain. As insulin resistance and fatty liver increase, weight management often presents as a challenge.

 

  • High free fatty acid levels in the bloodstream. Insulin resistance contributes to fatty liver and an increase in blood lipids.

 

  • Other cardiovascular risk factors including hypertension, abnormal blood coagulation (increasing risk of blood clots) and markers of inflammation.24 As Ruth Trickey explains in her text Women, Hormones and The Menstrual Cycle, “Women with the syndrome have at least seven times the risk of heart attacks and heart disease of other women.”

  

  • Inflammatory based diseases, due to the high insulin levels causing an increased level of inflammatory cytokines.

 

  • Oxidative stress and decreased antioxidant activity.

 

  • Stressed detoxification organs, due to the higher androgen levels. The result is an accumulation of endocrine disrupting chemicals, such as BPA, or pesticides.25

 

  • Progesterone Insufficiency. Conditions that promote either irregular or anovulatory (no ovulation) cycles, such as high stress and PCOS will contribute to progesterone deficiency. Ovulation needs to occur for a corpus luteum to be produced and therefore progesterone to be manufactured at higher levels.

 

  • Increased risk for abnormal endometrial cell growth and cancer. With lack of ovulation (anovulation) there is no corpus luteum development to increase progesterone levels, leading to unopposed oestrogen - a known contributor to abnormal endometrial growth.  

 

  • Abnormal uterine bleeding. Lack of ovulation contributes to low progesterone levels and the subsequent unopposed oestrogen, can lead to breakthrough bleeding.

 

 

  • Mood disturbances, anxiety, depression and eating disorders27 may be present, possibly contributed by the common physical manifestations of PCOS as well as the existing hormone imbalances.

 

  • Fertility challenges are highly prevalent among women with PCOS and is the leading cause of infertility in reproductive-aged women.28 This is caused by high androgen levels impairing oocyte development and contributing to higher miscarriage rates. Women with PCOS also have a higher risk of developing gestational diabetes, pregnancy induced high blood pressure and pre-eclampsia. Onto of these complications, in the case of an obese pregnant PCOS woman, insulin resistance will become more pronounced also impacting the developing foetus, and causing higher rates of miscarriage and caesarean births.29

Steps To Get A PCOS Diagnosis

In order to gain a PCOS diagnosis, you will need to make an appointment with your GP / Integrative GP to have a referral for the following tests:

1) Blood test for your androgen levels (DHEAS, testosterone, sex hormone binding globulin, free androgen index) as well as your day 3 LH/FSH ratio. A ratio of 2:1 or higher is evident in PCOS.

Oestrogen, progesterone and thyroid function tests will give you additional hormone health information.

2) Metabolic profile testing, including a blood test for fasting glucose tolerance test with insulin, HbA1c, as well as a detailed lipid profile is recommended. With a diagnosis of PCOS, these should be repeated regularly.29

2) Referral for an internal (transvaginal) ultrasound. They will be looking for the presence of 12 or more follicles 2-9mm in diameter, or increased ovarian volume >10mL in the follicular phase of your cycle.23

3) Your GP will want to discuss symptoms of high androgen levels, such as hirsutism, acne and head hair thinning.

4) Your personal cycle charting will provide great information for you and your health practitioners to identify signs of ovulation issues and/or luteal phase defect.

If your cycles have been impacted since coming off of the OCP in the lead-up to your preconception stage of life, this is how to determine what type of PCOS you are dealing with:

Hypothalamic Amenorrhea Diagnosis;

Remember, this is when you have no period after stopping pill, that is caused by underrating, overexercise and/or high stress.

Bloods will show:

  • Both LH and FSH are low
  • Low Oestrogen

Post Pill Induced PCOS Diagnosis:

When your periods were regular previous to starting the OCP, no periods after stopping the pill and possibly mild- moderate acne.

Bloods:

  • High LH:FSH (2:1 or more)
  • Normal fasting insulin <10 (if in Australia)

Ultrasound:

  • Polycystic ovaries possibly seen on an ultrasound

True PCOS:

Where there were irregular or absent periods before starting the OCP, irregular or absent periods since stopping the pill, and often showing acne symptoms.

Bloods will show:

  • High FSH: LH ratio
  • High Insulin >10

Ultrasound will show:

  • Often cysts shown on ovaries

 

Treatment Options

Following a low GI diet is an important first step in managing insulin resistance, promoting a healthy weight and treating PCOS.

A weight loss of just 5% can reduce insulin levels, improve cycle regularity and improve ovulation rates.30 

A first step here is to eliminate all refined carbohydrate intake (refined grain products such as pasta and conventional bread), products containing refined sugar as well as foods and drinks with high fructose levels, such as soft drink, fruit juice and foods containing agave and refined sugar. In saying that, our selection for gluten free,  sprouted breads and seed based crackers is increasing, which are lower GI and generally less inflammatory forming.

If your blood sugars, weight and cycle health are not improving, further restrictions in natural sugars are recommended. It is handy to use a blood glucose monitor (glaucometer) from your local chemist and use this to see how what your blood sugar levels are doing over the day as well as first thing after fasting overnight.  This is a powerful way at determining how your body handles carbohydrates and if further restriction to other carbs such as fruit, whole  grains and root vegetables are needed. Adding True Cinnamon to your foods and drinks can help balance blood sugars as well. Filling your plate up with loads of colourful low starch vegetables will provide you with antioxidants and fibre, adding ethically raised or grown protein to your meals and nourishing fats will also help to slow the release of your blood sugar levels and keep you satiated for longer. Avoid snacking to prevent unnecessary glucose spikes over the day.

Nutrients shown to improve blood sugar and insulin balance include Vitamin D, Magnesium, Alpha-Lipoic Acid, B Vitamins, Resveratrol, Omega 3 fats and the herb Gymnema. Human clinical trials of women with PCOS have also shown that Myo-Inositol and Folic acid supplementation reduces insulin resistance, improve overall metabolic health,31,32 hirsutism,33,34 regulates menstrual cycles,35 ovulation35 and is associated with enhanced fertility outcomes in when assisted reproductive technology is required.

Chromium has shown to decrease BMI, free Testosterone and fasting insulin levels in a meta-analysis and systemic review of seven studies involving 198 PCOS patients.32

As stated across on metagenicsinstitute.com.au...

Inositol and folic acid increase ovulation frequency in PCOS, as evidenced by improved luteal phase activity and normal progesterone concentrations.35 Ninety-two PCOS patients with oligomenorrhoea or amenorrhea receiving myo-inositol (4 g/d) and folic acid (400 µg/d) or a placebo for 14 weeks were evaluated for ovulation frequency and luteal activity. MYO and folic acid were shown to increase ovulation frequency (determined by adequate serum progesterone and normal LH levels) compared to the placebo group (p<0.001). Specifically, women in the treatment group experienced greater ovulation frequency across 14 weeks (two and four ovulations), compared to lower rates in the placebo group (between zero and one ovulations). In addition, active treatment was also associated with a reduction in days until first ovulation (24.5 days, compared to 40.5 days)…

Research also supports the combined use of inositol and folic acid in enhancing ART outcomes. These nutrients are associated with significant improvements in oocyte size and quality,36,37 ovulation rates38 and pregnancy rates,36,39as well as a reduction in the dose and duration of exogenous recombinant FSH treatment (rFSH) administered as part of ovarian hyperstimulation protocols.36,37

The foundation two-herb approach for PCOS is Licorice Root and White Peony, which can regulate the menstrual cycle and therefore protect the endometrium.  These two herbs are particularly helpful when you have the high LH levels and have shown to reduce testosterone levels40,41,42,43 and improve the oestradiol to testosterone rations just after four weeks of supplementation. Take short term, for 3-4 months and considering extra herbal medicine support if your cycle regularity has not improved within this time. Licorice is not recommended however when you have high blood pressure and if you are trying for a baby, these herbs should be discontinued after conception.

Vitex (also known as Chaste Tree) is a good option with Hypothalamic Amenorrhea but isn’t recommended if your LH levels are high, as it can aggravate your symptoms instead of normalising your cycle.

De-stressing practises and nutrients to build resilience are also important. Examples include Magnesium, B group vitamins and the herb Withania, which will also help support healthy thyroid and progesterone levels. If your stress is extreme, you may require additional anxiolytic herbs along with the amino acid L-Theanine, which promotes the calming neurotransmitter GABA, to calm your adrenal response and get you out of a state of fight or flight.

Daily movement is recommended along with dietary and lifestyle choices that help to balance your blood sugar levels, insulin sensitivity, promote a healthy weight range and reduce stress. 

Take Control Of PCOS

Once you have the awareness of a PCOS diagnosis and sub-type of PCOS you are experiencing and your personal contributing factors, be empowered to balance your whole body and hormones with a holistic health approach using dietary, lifestyle and supplementation support. Aim to overcome PCOS by:

  • Balancing your blood sugar levels and increasing insulin and leptin sensitivity
  • Controlling your androgen production, normalising Luteinising hormone and supporting your body’s production of progesterone.
  • Reducing and build resilience to stress
  • Reduce toxin exposure and enhance detoxification

If you are planning on starting or adding to your family, my Glowing Mumma preconception guide together with herbal and nutritional supplementation through your Naturopath, will provide you with comprehensive holistic support to address these factors. See further information across in the show notes.

When you take control of your PCOS by addressing your underlying cause, utilising nutrition and natural medicine to rebalance your hormones and weight, you will be mesmerised with how your body can heal and your cycles and fertility return once again.

 References: Linked throughout + 

8) Willis D, Mason H, Gilling Smith C, et al. Modulation by insulin of follicle stimulating hormone and Luteinising Hormone actions in human granulose cells of normal and polycystic ovaries. J Clin Endocrinol Metab 1996;81:302-9.

10) Merkin SS, Phy JL, Sites CK, et al. Environmental determinants of polycystic ovary syndrome. Fertil Steril 2016;106(1):16-24.

16) Sgarlata C. PCOS Natural Fertility Masterclass Program. Viewed March 2016, https://www.healthmasterslive.com.

18) Durant E, Leslie NS. Polycystic ovarian syndrome: loss of the apoptotic mechanism in the ovarian follicles? J Clin Endocrinol Metab 1998;21:552-7.

26) Arora S1, Sinha K1, Kolte S1, Mandal A1. Endocrinal and autoimmune linkage: Evidences from a controlled study of subjects with polycystic ovarian syndrome. J Hum Reprod Sci. 2016 Jan-Mar;9(1):18-22.

28) Dumont A, Robin G, Catteau-Jonard S, Dewailly D. Role of Anti-Müllerian Hormone in pathophysiology, diagnosis and treatment of polycystic ovary syndrome: a review. Reprod Biol Endocrinol. 2015 Dec 21;13:137. doi:10.1186/s12958-015-0134-9.

39) Emekçi Özay Ö, Özay AC, Çağlıyan E, Okyay RE, Gülekli B. Myo-inositol administration positively effects ovulation induction and intrauterine insemination in patients with polycystic ovary syndrome: a prospective, controlled, randomized trial. Gynecol Endocrinol. 2017 Jul;33(7):524-528. doi: 10.1080/09513590.2017.1296127.  

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