Are you experiencing cycle, skin, weight and/ or unwanted hair growth symptoms? Has Dr Google has lead you to Polycystic Ovarian Syndrome (PCOS) as a possibility? Or perhaps you've been given a diagnosis of PCOS by your GP, but you really don't know where to go from here?
Read on to gain an understanding of what PCOS is, the signs, symptoms, causes, consequences of and how you can get a diagnosis, so you can seek the guidance you need to support your hormones, cycle and body back to balance.
Polycystic ovarian syndrome (PCOS) is a hormone disorder with increasing prevalence and now affecting 1 in 5 Australian women of a child bearing age and 1 in 7 world wide.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 an overall increased level of androgen production.
The heightened androgen production is contributed by an elevated Luteinising Hormone (LH) to Follicle Stimulating hormone ratio (produced from your pituitary gland, in the brain), and often an increased production of insulin from the 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 the 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 prevent a normal (short term) LH surge required for ovulation each month. Without ovulation, periods are irregular 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.
Early menarche, a family history of PCOS, together with a preexisting 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. A diet high in glucose and fructose containing foods contribute to a condition of insulin resistance and can lead to weight gain and type 2 diabetes.
Insulin resistance is also a known driver for adrenal, thyroid and sex hormone imbalance. 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.5
Insulin resistance also has the potential to increase oestrogen (testosterone is still higher proportionally) and this increased oestrogen suppresses FSH, 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. Over time, insulin and leptin resistance can contribute to PCOS.
Central obesity is common in PCOS and has shown to be a factor of fertility issues.6 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 (an enzyme allowing the conversion of androgens into oestrogens).6
In response to stress, DHEA/ DHEA-S and androstenidione levels are produced from your adrenal glands (via the HPA Axis). 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.
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:
In the state of an under active thyroid, phase II elimination of sex hormones in your liver, including testosterone, is slowed and a buildup effect can occur.7
Inflammation & Gut health
Inflammation can impact your gut health and encourage beta-glucuronidase enzyme activity.8 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.
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. Most shockingly, a mothers exposure to BPA during pregnancy has been linked to PCOS development in female children.9,10,11
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 11-16 days, but must be at least 11 days 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.
It is important to firstly note that not all cases of PCOS include polycystic ovaries, which show up on an internal (transvaginal) ultrasound.
Other important diagnostic factors for the condition of PCOS, include:
The full list of PCOS signs & symptoms, include:
Living with the high insulin, luteinising hormone, androgen levels and weight challenges of PCOS, increases the chance of developing health conditions. These include:14,15,16,17
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 3:1 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.23
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.18
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. Learn more about cycle charting in my Instagram live with Naturopath Kirsty King, here.
Once you have the awareness of a PCOS diagnosis and your personal contributing factors, be empowered to balance your whole body and hormones within Balanced, The Natural Way To Healthy Hormones. This will give you the tools you need to begin dietary, lifestyle and supplementation support for PCOS, including:
If you are seeing a health practitioner, this book will also give you an understanding of your holistic health treatment. You can pick up your eBook or physical copy of Balanced, The Natural Way To Healthy Hormones here.
1) Norman RJ, Dewailly D, Legro RS, et al. Polycystic ovarian syndrome. Lancet 2007;370:685-97.
2) Boyle J, Teede HJ. Polycystic ovarian system. An update. Aust Fam Physician 2012;41(10):752-756.3) van der Spuy ZM, Dyer SJ. The pathogenesis of infertility and early pregnancy loss in polycystic ovarian syndrome. Best Pract Res Clinger's Obstet Gynaecol 2004;18(5):755-71.
3) Carmina E, Rosato F, Janni A, et al. Extensive clinical experience: relative prevalence of different androgen excess in 950 women referred because of clinical hyperandrogegism. J Clinger's Endocrinol Metab 2006;91:2-6.
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Merkin SS, Phy JL, Sites CK, et al. Environmental determinants of polycystic ovary syndrome. Fertil Steril 2016;106(1):16-24.
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Chang WY, Knochenhaut ES, Bartolucci AA, et al. Phenotypic spectrum of polycystic ovarian syndrome: clinical and biochemical characterisation of the three major subgroups. Fertilities Steril 2005;83:1717-23.
Gilling-Smith C, Willis DS, Beard RW, et al. Hypersecretion of androstenedione by isolated thecal cells from polycystic ovaries. J Clin Endocrinol Metab 1994;79(4):1158-65.