Polycystic ovarian syndrome (PCOS) is a disorder that has undergone many changes in diagnostic criteria over the last 30 years. Previously, the diagnosis was based on the presence of polycystic ovaries (PCO): an increased number of follicles in each ovary and/or an abnormally large ovarian volume. But the multi-system involvement in PCOS has led to multiple versions or subtypes of the disorder. PCOS and PCO are associated with metabolic and hormonal dysfunction including insulin resistance and the resulting high levels of androgens, such as testosterone. The result of this dysfunction is the characteristically high number of immature follicles within the
Polycystic ovary syndrome (PCOS) is considered one of the leading endocrine disorders affecting up to 10% of all women of reproductive age.1 It is a complex disorder stemming from inappropriate hypothalamic-pituitary- ovarian interaction (see the article titled “An introduction to the HPG Axis”), thought to be one of the leading causes of infertility. Why and how PCOS develops is not yet understood, although accumulating evidence suggests that it may be mostly genetic.2,3
Diagnosis, Symptoms and Risks
A PCOS diagnosis is based on menstrual irregularity, excessive
The principal symptoms of PCOS emerge
late in puberty or shortly after, stemming from two main causes: 1) a lack of
ovulation, which may or may
not result in irregular menstruation, and 2) excessive amounts (or due to the effects) of androgenic hormones, which cause hirsutism (excessive facial and body hair).2,3 It is not uncommon for women with PCOS to encounter other difficulties such as infertility, high risk of miscarriage, accumulation of visceral fat, obesity, various cardiovascular diseases such as diabetes, dyslipidemia, hypertension, and Metabolic Syndrome later in life.3-8 The severity of symptoms, especially hirsutism and obesity, can lead to feelings of low self-esteem, anxiety, depression and low quality of life.9
Currently, four categories of PCOS have been identified.14 The first is characterized by the presence of menstrual irregularities, polycystic ovaries and hyperandrogenemia (excessive masculinizing hormones),
Early diagnosis and preventative measures are of the utmost importance in promoting long-term health, decreasing the risk of developing other secondary illnesses, and even preventing the development of cardiovascular diseases.15 However, due to the individualized nature of PCOS, management must be tailored to target the displayed symptoms and to prevent the risk factors that you may have a predisposition for. It is also important to monitor progress and the development of new symptoms, and change the management routine accordingly.
Dietary and Lifestyle Changes
First line therapy for women with PCOS, and the only therapy incurring lifelong benefits with minimal side
Lifestyle changes can also have an impact on PCOS symptoms. It was shown that 1 hour of exercise (aerobic, resistance, or endurance) three times per week for 12-16 weeks, significantly improved insulin resistance, ovarian hormones, and reproductive function.23-26 It was also shown that the addition of aerobic or combined aerobic-resistance exercise to a calorie restricted diet significantly improved body composition in overweight and obese women with PCOS compared to those on a low calorie diet only.27
Even if healthy dietary and lifestyle options alone are not enough, a healthy lifestyle can significantly improve the success rate of
Supplementation Some women with PCOS may not achieve adequate symptom relief from dietary and lifestyle changes alone, and therefore they may seek natural interventions to boost the results of healthy lifestyle modifications.
Chromium: To reduce the risk of developing type 2 diabetes, it is crucial to reduce insulin resistance. Chromium is a well-known element that has been found to reduce high insulin at doses of 200-1000 mcg/day, and the picolinate salt was found to be the most bioavailable chromium salt.28 Interestingly, circulating serum chromium has been found to be low in women with PCOS, and was directly correlated with fasting insulin levels.29 The same study also found that women with PCOS had lower serum manganese and magnesium, but higher serum calcium, zinc and copper than women without PCOS, and the differences were more pronounced in women with PCOS and insulin resistance.29
Cinnamon & Gymnema: Cinnamon was also
Folate: Folate (L-5- methyltetrahydrofolate, L-5-MTHF) is a crucial B vitamin especially for any woman looking to conceive, as it is a simple way to prevent neural tube defects in developing fetuses. However, it can also help reduce homocysteine, which is associated with recurrent pregnancy loss and an increased risk of cardiovascular disorders including dyslipidemia and blood clot formation.29,38 Folate intake was shown to significantly reduce homocysteine levels in women with PCOS 39 at doses between 400-1000 mcg. However many women can’t even metabolize regular supplemental folate due to a common genetic mutation that makes them unable to convert the folate to its active form, L-5-MTHF. 40 This can be overcome by directly supplementing with the bioactive folate form, L-5- MTHF.
Inositol: The development of insulin resistance may be linked to a deficiency in inositol, which is a messenger needed for insulin signaling.41 The human body contains two forms of inositol, myo-inositol (the most abundant form), and D-chiro-inositol; the ratios of each are different in each organ depending on that organ’s needs. Ovaries require a high level of myo-inositol, in fact, a link between high concentrations of myo-inositol and quality, mature oocytes (egg cells) has been established.42 It is therefore not surprising that supplementing with myo-inositol (4 g/day) during in vitro fertilization treatments have been shown to significantly improve oocyte quality, improving the chance of developing a healthy embryo by improving insulin sensitivity.43-45 However, evidence on D-chiro-inositol supplementation is controversial, with a recent study even showing worsening of oocyte quality and reduced ovarian response to fertility treatments.46
Melatonin: Melatonin supplementation was also found to improve oocyte quality and pregnancy rates in women undergoing in vitro fertilization.47 Melatonin reduces oxidative stress within the follicle. Oxidative stress increases significantly during the ovulatory process and is suspected to be a cause of poor oocyte quality.48 The addition of 3 mg/day of melatonin to myo-inositol and folic acid supplementation significantly improves oocyte quality and pregnancy outcome in women with poor oocyte quality.49
Omega-3s: Supplementing with omega-3 fatty acids was shown to significantly reduce liver fat content, thereby preventing or reducing fatty liver disease, in addition to improving serum adiponectin levels (a protein involved in regulating glucose levels as well as fatty acid breakdown), insulin resistance and cholesterol in women with PCOS49,50 while another group showed that greater plasma polyunsaturated fatty acids, particularly long chain omega-3s, improve the androgenic profile in women with PCOS.51
Anti-androgenic herbs: These can be used to lower androgen levels in women with PCOS, helping to reduce hirsutism and balding. Spearmint herbal tea was shown to have significant anti-androgen effects in polycystic women; however, because hirsutism and balding require more time to resolve in response to lowering androgen levels, the short duration of the trials did not permit them to decrease significantly. However, it is expected that longer term intake of spearmint tea would produce significant results.52,53 While other known anti-androgen herbs like saw palmetto and standardized pollen extracts have not been studied in women with PCOS, their well- known anti-androgenic properties are expected to reduce symptoms of high androgen levels in women with PCOS. Anti-androgenic supplementation or medication must not be taken during pregnancy or when trying to conceive however, as they have the potential of feminizing male fetuses.
Soy isoflavones: There are many options available to manage high cholesterol levels and improve the body’s lipid profile. Soy isoflavones have been studied in women with PCOS, and an intake of 36 mg/day of genistein for six months in dyslipidemic women improved their lipid profiles.54
Somewomenmayoptforprescription medication, and in severe cases, surgical intervention may be warranted. It must be noted however that lifestyle changes, including healthy diet and
For hirsutism, there are many available options. Tweezing, waxing, sugaring and shaving are the cheapest methods; however, these only provide temporary relief. More permanent relief can be provided with electrolysis or laser hair removal. Permanent hair reduction with either laser or electrolysis may take up to two years to significantly reduce hair growth.
Being diagnosed with PCOS may seem
daunting and overwhelming, and although
it is a lifelong condition with no cure, it is highly manageable.
Key to“Should I Ask My Doctor if I Have PCOS?”
Award 1 point each if you: Q1: Answered c, d or e Q2: Circled 3 or more sites Q3: Answered“yes”
For Q4, if you answered“yes”, then subtract 1 point, if you answered“no” then don’t change your points.
If you get ≥2 points, then you may have PCOS and should speak to your doctor.
1. Zhao Y et al. Ethnic Differences in the Phenotypic Expression of Polycystic Ovary Syndrome. 2013. Steroids; 78(8): 755-760.
2. Robboy S et al. The Female Reproductive System. In: Rubin E, Farber JL. Pathology. 3rd ed. Philadelphia, PA: Lippincott-Raven Publishers; 1999:1003-1004.
3. Chang RJ. The Reproductive Phenotype in Polycystic Ovary Syndrome. Endocrinology & Metabolism. Jul 2007;3(10):688-695.
4. Ehrmann D et al. Prevalence of Impaired Glucose Tolerance and Diabetes in Women with Polycystic Ovary Syndrome. 1999. Diabetes Care;22(1):141-6.
5. Ehrmann D. Polycystic Ovary Syndrome. 2005. N Eng J Med;352(12):1223-36.
6. Mather K et al. Hyperinsulinemia in Polycystic Ovary Syndrome Correlates with Increased Cardiovascular Risk Independent of Obesity. 2000. Fertil Steril;73(1):150-6.
7. Holte J et al. Elevated Ambulatory Daytime Blood Pressure in Women with Polycystic Ovary Syndrome: A Sign of A Pre-hypertensive State? 1996. Hum Reprod;11:23-8.
8. Badawy A et al. Treatment Options for Polycystic Ovary Syndrome. 2011. Int J Womens Health; 3:25-35
9. Teede H et al. Polycystic Ovary Syndrome: A Complex Condition with Psychological, Reproductive and Metabolic Manifestations that Impacts on Health Across the Lifespan. 2010. BMC Med; 8:41
10. Hsu M. Changes in the PCOS Phenotype with Age. 2013. Steroids; 78(8):761-766.
12. Lim S. The Effect of Obesity on Polycystic Ovary Syndrome: A Systematic Review and Meta-analysis. Obes Rev. Feb 2013; 14(2):95-109.
13. Panidis D et al. Insulin Resistance and endocrine Characteristics of the Different Phenotypes of Polycystic Ovary Syndrome: A
14. Huang G et al. Clinical Update on Screening, Diagnosis
15. Cussons A et al. Polycystic Ovarian Syndrome: Marked Differences Between Endocrinologists and Gynaecologists in Diagnosis and Management. 2005. Clin
16. Yildirim B et al. Relation of Intra-Abdominal Fat Distribution to Metabolic Disorders in Non-Obese Patients with Polycystic Ovary Syndrome.2003. Fertil Steril; 79:1358-1364.
17. Stankiewicz M et al. Diagnosis and Management of Polycystic Ovary Syndrome – A
18. Motta A. The Role of Obesity in the Development of Polycystic Ovary Syndrome. 2012. Curr Pharm Des; 18(17):2482-2491.
19. Liepa G et al. Polycystic Ovary Syndrome (PCOS) and Other Androgen Excess-Related Conditions; Can Changes in Dietary Intake Make a Difference? 2008. Nutr Clin Pract; 23:63-71.
20. Mavropoulos J et al. The Effects of a Low-Carbohydrate, Ketogenic Diet on The Polycystic Ovary Syndrome: A Pilot Study. 2005. Nutr Metab; 2:35–46.
21. Jakubowicz D et al. Effects of Caloric Intake Timing on Insulin Resistance and Hyperandrogenism in Lean women with Polycystic Ovary Syndrome. 2013. Clinical Science;125:423-432.
22. Harrison C et al. The Impact of Intensified Exercise Training on Insulin Resistance and Fitness in Overweight and Obese women with and without Polycystic Ovary Syndrome. 2012. Clin Endocrinol (Oxf); 76(3):351-357.
23. Joham A et al. Pigment Epithelium-Derived Factor, Insulin Sensitivity, and Adiposity in Polycystic Ovary Syndrome: Impact of Exercise Training. 2012. Obesity (Silver Spring); 20(12):2390-2396.
24. Moran L et al. Exercise Decreases Anti-Müllerian Hormone in Anovulatory Overweight Women with Polycystic Ovary Syndrome: A Pilot Study. 2011. Horm Metab Res. ;43(13):977-9.
25. Nybacka A et al. Randomized Comparison of The Influence of Dietary Management and/or Physical Exercise on Ovarian Function
26. Thomson R et al. The Effect of a Hypocaloric Diet with and without Exercise Training on Body Composition, Cardiometabolic Risk Profile, and Reproductive Function in Overweight and Obese Women with Polycystic Ovary Syndrome. 2008. J Clin Endocrinol Metab; 93(9):3373-3380.
27. Power M et al. Alternative and Complementary Treatments for Metabolic Syndrome. 2011. Curr Diab Rep; 11:173-178.
28. Chakraborty P et al. Recurrent Pregnancy Loss in Polycystic Ovary Syndrome: Role of Hyperhomocysteinemia and Insulin Resistance. 2013. PLoS One; 8(5):e64446.
29. Wang J et al. The effect of Cinnamon Extract on Insulin Resistance Parameters in Polycystic Ovary Syndrome: A Pilot Study. 2007. Fertil Steril; 88:240-243.
30. Leach M et al. Gymnema sylvestre for Diabetes Mellitus: A Systematic Review. 2007. The journal of Alternative and Complementary Medicine; 13(9):977-983.
31. Wehr E et al. Association of Hypovitaminosis D with Metabolic Disturbances in Polycystic Ovary Syndrome. 2009. Eur J Endocrinol. 161(4):575-82.
32. Hahn S et al. Low Serum 25-hydroxyvitamin D Concentrations Are Associated With Insulin Resistance and Obesity in Women with Polycystic Ovary Syndrome. 2006. Exp Clin Endocrinol Diabetes;114(10):577-583.
33. Pal L et al. Therapeutic Implications of Vitamin D and Calcium in Overweight Women with Polycystic Ovary Syndrome. 2012. Gynecol Endocrinol; 28(12):965-968.
34. Firouzabadi R et al. Therapeutic Effects of Calcium & Vitamin D Supplementation in Women with PCOS. 2012. Complement Ther Clin Pract. 18(2):85-88.
35. Rashidi B et al. The Effects of Calcium-Vitamin D and Metformin on Polycystic Ovary Syndrome: A Pilot Study. 2009. Taiwan J Obstet Gynecol; 48(2):142-147.
36. Wehr E et al. Effect of Vitamin D3 Treatment on Glucose Metabolism and Menstrual Frequency in Polycystic Ovary Syndrome Women: A Pilot Study. 2011. J Endocrinol Invest; 30(10):757-763.
37. Audeline M et al. Homocysteine and Cardiovascular Disease in Diabetes Mellitus. 2001. Atherosclerosis; 159:497-511.
38. Kazerooni T et al. Effect of Folic Acid in Women with and without Insulin Resistance who have Hyperhomocysteinemic Polycystic Ovary Syndrome. 2008. Int J Gynaecol Obstet; 101(2):156-160.
39. Zhang T et al. Genetic Variants in the Folate Pathway and the Risk of Neural Tube Defects: A Meta-Analysis of the Published Literature. 2013. PLoS One; 8(4):e59570.
40. Huang et al. Chiro-Inositol Deficiency and Insulin Resistance. III. Acute Glycogenic and Hypoglycemic Effects of Two Inositol Phosphoglycan Insulin Mediators in Normal and Streptozotocin-Diabetic Rats in vivo. 1993. Endocrinology; 132:652-657.
41. Chiu T et al. Follicular Fluid and Serum Concentrations of Myo-Inositol in Patients Undergoing IVF: Relationship with Oocyte Quality. 2002 Hum Reprod.17(6):1591-1596.
42. Papaleo E et al. Myo-inositol May Improve Oocyte Quality in Intracytoplasmic Sperm Injection Cycles. A Prospective, controlled, Randomized Trial. 2009. Fertil Steril. 91(5):1750-1754.
43. Unfer V et al. Effects of Myo-Inositol in Women with PCOS: A Systematic Review of Randomized Controlled trials. 2012. Gynecol Endocrinol; 28(7):509-515.
44. Genazzani A et al. Differential Insulin Response to Myo-Inositol Administration in Obese Polycystic Ovary Syndrome Patients. 2012. Gynecol Endocrinol; 28(120):969-973.
45. Isabella R et al. Does Ovary Need D-Chiro-Inositol? 2012. J Ovarian Res; 5:19.
46. Batıoğlu A et al. The Efficacy of Melatonin Administration on Oocyte Quality. 2012. Gynecological Endocrinoliogy; 28(2):91-93.
47. Sugino N. Reactive Oxygen Species in Ovarian Physiology. 2005. Reprod Med;4:31-44.
48. Rizzo P et al. Effect of the Treatment with Myo-Inositol Plus Folic Acid Plus Melatonin in Comparison with a Treatment with Myo-Inositol Plus Folic Acid on Oocyte Quality and Pregnancy Outcome in IVF Cycles. A Prospective, Clinical trial. 2010. Eur Rev Med Pharmacol Sci; 14(6):555-561.
49. Cussons A et a. Omega-3 Fatty Acid Supplementation Decreases Liver Fat Content in Polycystic Ovary Syndrome: A Randomized Controlled Trial Employing Proton Magnetic Resonance Spectroscopy. 2009. J Clin Endocrin Metabo; 94(10)3842-8.
50. Mohammadi E et al. Effects Of Omega-3 Fatty Acids Supplementation on Serum Adiponectin Levels and Some Metabolic Risk Factors in Women with Polycystic Ovary Syndrome. 2012. Asia Pac J Clin Nutr;21(4):511-518.
51. Phelan N et al. Hormonal and Metabolic Effects of Polyunsaturated Fatty Acids in Young Women with Polycystic Ovary Syndrome: Results from a Cross-Sectional Analysis And A Randomized, Placebo-Controlled, Crossover Trial. 2011. Am J Clin Nutr; 93(3): 652-662.
52. Grant P. Spearmint Tea Has Significant anti-Androgen Effects in Polycystic Ovarian Syndrome: A Randomized Controlled Trial. Phtother Res. Feb 2010. 24(2):186-188
53. Akdoğan M et al. Effect of Spearmint (Mentha spicata Labiatae) Teas on Androgen Levels in Women with Hersutism. 2007. Phytother Res; 21(5):444-447.
54. Romualdi D et al. In There a Role for Soy Isoflavones in the Therapeutic Approach to Polycystic Ovary Syndrome? Results from a Pilot Study. 2008. Fertil Steril;90(5):1826-1833.
55. Bates G et al. Medical and Surgical Management of Common Fertility Issues: Polycystic Ovarian Syndrome Management Options. 2012. Obstetrics and Gynecology Clinics; 39(4):495-506.
56. Giallauria F et al. Cardiovascular Risk in Women with Polycystic Ovary Syndrome. 2008. Journal of Cardiovascular Medicine;9(10):987-992.
57. Pedersen SD et al. Polycystic Ovary Syndrome: Validated Questionnaire for Use in Diagnosis. Can Fam Physician. 2007; 53:1041-1047.