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 production of androgens (masculinizing hormones) or excessive masculinizing traits (such as balding, excessive body and facial hair), as  well as the presence of ovarian cysts. However, all other possible causes of the above mentioned traits have to be excluded for a diagnosis of PCOS to be made.^2,3 There are many connections between the various factors involved in the development of PCOS but how they all fit together has not been conclusively determined.³

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

Severity of symptoms and related disorders of PCOS vary greatly between individuals, yet there are some trends that have been observed with age and ethnicity. In younger women with PCOS, hyperandrogenism (excessive androgens) and chronic anovulation (lack of ovulation) are the primary disturbances, whereas, obesity, insulin resistance, and metabolic disturbances are predominant in older women with PCOS.¹⁰ South Asians with PCOS have a high prevalence of insulin resistance and metabolic syndrome, and are at risk for type 2 diabetes. African American and Hispanic women with PCOS are more prone to obesity and metabolic problems. Finally, there is a higher prevalence of hirsutism among women of Middle Eastern and Mediterranean origin that suffer from PCOS.1 PCOS  is also associated with other conditions including Acanthosis nigricans (hyperpigmentation of folds in the skin),¹¹ fatty liver disease, obstructive sleep apnea, carcinoma (malignant cancer cells), and potentially breast, endometrial or ovarian cancer.^5,12 Interestingly, insulin resistance and obesity can further amplify the severity of the condition and its symptoms, creating a vicious cycle where the symptoms exacerbate the condition and the condition exacerbates the symptoms.¹³

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), andis presentin~48% of all women with PCOS. The second is characterized by the presence of menstrual irregularities and hyperandrogenemia only, and is found in 31% of women with PCOS. The third is characterized by the presence of hyperandrogenemia and polycystic ovaries only and is present in 10% of women with PCOS. Finally, the fourth category is characterized by the presence of menstrual irregularities and polycystic ovaries only and is present in 11% of women with PCOS.¹⁴ Panidis and colleagues (2012) identified the following trends: both lean and overweight/obese women in PCOS categories 1 and 2 are at a higher risk for insulin resistance than those without PCOS, while only obese/overweight women in the fourth category share the same risk. Overweight women in the first category, however, have the highest risk for insulin resistance. Serum androgen levels are highest in both lean and overweight/obese women in PCOS categories one to three compared to those in the fourth.¹⁴

Management

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 effects, is the reduction of central abdominal fat in all women, and weight loss in overweight and obese women.¹⁶ Abdominal fat is the most common fat distributionfoundinwomenwith PCOS whether they’re lean or overweight.¹⁷ Visceral fat, especially in obesity, has been found to increase some features of PCOS such as infertility, pregnancy complications and hyperandrogenism including hirsutism, and in combination with insulin resistance it can increase the risk for type 2 diabetes and cardiovascular diseases.^17,18 The reduction of abdominal fat in all women with PCOS and weight loss in overweight and obese women can also help prevent long-term complications of the condition by improving quality of life, correcting hyperinsulinemia, improving fertility and improving lipid and androgen profiles.¹⁸ In fact, it has been found that after losing only 5%  of initial body weight, obese women with PCOS had improved menstrual regularity, ovulation and pregnancy rates within weeks.^18,19 In order to best reduce insulin resistance and reduce the risk of type  2 diabetes, improve lipid profiles and reduce androgen production, diet recommendations for women with PCOSaresimilartothoserecommended for type 2 diabetics. A high-fiber, low- glycemic-index diet with adequate protein and an emphasis on unsaturated fatty acids (especially ω-3 fatty acids) is recommended, while also maintaining a high intake of anti-inflammatory and antioxidant nutrients such as vitamin E and moderate amounts of red wine.²⁰ A reduced calorie diet is recommended for obese and overweight women, while adequate calories for maintenance are more appropriate for lean women.²⁰ An extreme version of a low carbohydrate diet called a “ketogenic diet”, in which the ratio of carbohydrates to proteins to fat is maintained at 10:30:60, was found to significantly decrease insulin resistance, free testosterone, and weight in overweight women with PCOS.²¹ However  it  is   not   recommended   to maintain a ketogenic diet for a prolonged period of time as research on long term safety is lacking; a doctor should be consulted  prior  to  starting a ketogenic diet. Timing of caloric intake can also have an effect on PCOS symptoms in lean women; it was shown that a breakfast with more calories than dinner improved insulin sensitivity compared to a dinner with more calories than breakfast.²²

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 other supplemental, pharmaceutical and surgical interventions. In fact, returning to a less healthy lifestyle and weight gain can easily reverse all the benefits that were obtained by exercise and healthy eating.

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 shown to significantly reduce insulin resistance in women with PCOS compared to placebo.³⁰ Additionally, Gymnema sylvestre, although not yet studied in women with PCOS, is a well-known herb used for lowering insulin resistance and supporting the management of diabetes.³¹

Vitamin D: Lowvitamin Dwasshown to be associated with components of metabolic syndrome in women with PCOS,  which  include hyperlipidemia insulin resistance, diabetes, obesity, and various other metabolic conditions.^32,33 It was shown that vitamin D and calcium supplementation in overweight women with PCOS improved androgen and blood pressure profiles,³⁴ and in infertile women it improved weight loss, follicle maturation and menstrual regularity.^35,39 In another study, vitamin D supplementation in women with PCOS improved glucose metabolism and menstrual frequency.³⁷

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 PCOS^49,50 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

Other Options

Somewomenmayoptforprescription medication, and in severe cases, surgical intervention may be warranted. It must be noted however that lifestyle changes, including healthy diet and exercise are crucial to maintain results, no matter what other interventions are used.

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.

Understanding yourownsymptoms and working closely with your doctor are the first steps toward effective and targeted therapy. It is crucial to get diagnosed at the earliest stages of the disease in order to have the best chance at reducing the risk of, or even preventing, progression of the condition or  the  development of complications. A healthy lifestyle, including consistent exercise and a diet high in anti-inflammatory nutrients, antioxidants, fiber and proteins while low in carbohydrates is the first line of therapy toward managing symptoms of PCOS. In addition to a healthy lifestyle, supplements or medication may be used to target any other symptoms that do not resolve with healthy lifestyle modifications alone.

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.

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