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I Failed, Gained 15 Pounds and Saved my Life (Or Something)

Posted by on Jan 21, 2014 in Blog, Disordered Eating, Hormones, HPA axis, Hypothalamic Amenorrhea, PCOS | 27 comments

I Failed, Gained 15 Pounds and Saved my Life (Or Something)

The one thing that we talk about most in this community is how to be in hormone balance. How to be fertile. How to enjoy being a woman instead of constantly fighting the basic facts of natural womanhood. Every day I send emails to women making recommendations regarding food choices, lab tests, and self-love and body image issues. I thought it perhaps best, then, to share with you the differences I have experienced at different points in my life regarding my hormone balance.

Pre-weight loss; pre-exercise-binger; pre-paleo

As an adolescent and very young adult, I had some but not extreme acne. I weighed 137 pounds at my “heaviest,” which at 5’2 is approximately a size 7, and on my larger days a 9. I was also quite stressed out so did not menstruate super regularly, but still menstruated on a fairly regular basis. My periods were not always, though sometimes, incredibly painful, and lasted approximately 6-8 days. I do not have any good photos from the time (and I deleted off of my facebook any of the ones that actually showed my body fatness… choosing to leave tagged only those photos that were most flattered). But here is what I looked like, more or less:



(College “I’m drunk meditating on the side of the road in Beijing” phase)



(College “I’m dressed as a fairy holding the ‘make out’ hat” and “this photo is actually super flattering” phase)

Yet I dug up one from another angle in which I appear a bit less flat:


(Yes, I’m kissing someone, not a phase.)


(College  ”I’m a crunchy hippy” phase)


Enter “success”

In the fall of 2009 I finally achieved the momentum I needed on my low fat, low calorie, vegetarian diet, 90-minute-sprint-workouts-every-day regimen to shrink down to, at my lowest, I think I was probably around 105 pounds. I bounced back up to 115 for the next few years but I still wore size zero, 25 inch waist pants.

In this time period, I experienced:

-the complete cessation and continued absence of anything resembling a sex drive

-an vagina that was, all of the time, as dry as Oscar Wilde (if not more so-if such a thing is possible)

-a completely absent menstrual cycle

-cystic acne

-constant hunger (though I did not know it at the time since I had yet to experience the real cycle of intuitive eating yet)

These five bullet points might not look like much – but when you’re a woman who prided herself on her voracious sex drive and then it completely vanished, and you became infertile, and had acne… the thing was, I always suspected that my weight was to blame for my acne, at least in part, but I always thought it still worth the trade off. I’d rather have acne and be thin than be fat with clear skin.


This is what I looked like in this time period:


(“I cover my face because the sun burns my acne” phase)


(“I have eight pack abs, so what, b*tches?” phase)


(“Thigh gap!” phase)


(“Holy crap I’m so comfortable in this tiny body please don’t take it away” phase)


Lots of women probably menstruate at the size I was in the photos above. They probably had sex drives. I did not. All I had managed was to salvage my skin, mostly by reducing the fiber and protein contents of my diet, as well as by adding a topical probiotic to my daily regimen and ceasing to use conventional soaps and such. I had also managed to ovulate a few times, mostly by radically reducing stress or by having a particularly potent sexual encounter, but I did not have a true menstrual cycle, not by a long shot.

I also ate paleo the whole time, so anyone who says all you need to be healthy is a paleo diet is woefully uninformed.


Enter “failure”

Then came a time in which I prioritized my work and energy over everything else, and was extraordinarily stressed out. I gained weight. fast. And surprise of surprises, I menstruated. (Literally, it smacked me right out of the blue.) My sex drive had steadily increased up until that day, and has remained not just “oh thank god sex doesn’t disgust me anymore” or “well sure I’ll kiss you I guess” but “holy crap I want to do it now” since then. I have continued to cycle since. And my skin has cleared, almost entirely (to be fair: my stress has also been radically reduced), and I have, to my mingled dismay/resignation/fear/acceptance, continued to gain weight.

This is what a Stefani that can menstruate looks like:

AJP (C) --38

(“I’m such a big deal I do photoshoots and holy crap I’ve got hips” phase)


 (“Holy crap back fat stomach fat” phase)


(“Bear in mind that the camera on my phone elongates and I’m not nearly this tall or slim” phase)

If you want to see a video of me partner dancing in a body that menstruates (which is, still, a size or two smaller than I am now, I am more than happy to invite you to do so, here).


Looking at these photos, you might hardly see a difference. So what, you say. ”She’s not overweight.” 

No, of course not. I agree. I mean — there is definitely a difference, and just about everybody in my life has remarked upon it. My thighs are about 3 inches thicker, each. My face “fuller.” My abs, gone. My periods, pain free, and quite short (thanks to paleo!). I used to be a size 26 jean, and last night I wore a 30. I can no longer wear any outfit with carefree abandon — I now have to worry about placement and what the most flattering cut is and how to handle the parts of my that jiggle. 

Some people say I look better. I don’t know. Can I compare? I don’t know. I know I look different, and that’s all that has mattered, and all that made this, while on one hand the best thing in my life, also, on the other hand, one of the harder things I have done (at least in 2014 :) ). 

It’s been a small difference, but I had to read my own writing, and reach out to others for reassurance, and make a deliberate effort to arm myself against the tides of psychological baggage that tells me putting on weight makes me a failure, marks me as lazy, and renders me unfit for love. I believe so strongly in allegiance to our natural bodies, but that does not mean that I still did/do not have to fight for it on my “bad” days. Only because the gains I have had have been so great – I’m never giving up sex again — and because I have such loving, supportive people in my life, and because I’m currently finishing editing a book all about self-love, was I able to fall asleep peacefully at night rather than in a fit of frustrated, frightened tears.

Our society makes it hard. Even at my own relatively small weight gain and size. It makes it hard to “lose ground.” It makes it hard to “backslide.” But that doesn’t mean we give up. We remind ourselves of our own inherent worth, and we push through, and we change the face of womanhood one woman at a time.

I am no longer a fitness champion. I can no longer compare myself to Victoria’s Secret models. But I am different. I’m a new kind of sexy (more about which in coming days). I am me. And I am happy, and fertile, and healthy, and alive.

Hell. Yes. 

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Ask Stefani: PCOS Edition

Posted by on Jan 28, 2013 in Blog, Disordered Eating, Hormones, PCOS | 5 comments

Ask Stefani: PCOS Edition

More questions about PCOS this afternoon!   No surprises here.  Below are some thoughts on endometriosis and PCOS, quinoa, feeling restricted, allergies, and moving forward with hypothalamic amenorrhea.

If you find that a question you asked me is below and I have not stripped it enough of your personality to post it here, please let me know.


Help!  I have both endometriosis and PCOS.  I don’t understand– I thought endometriosis was a condition of high estrogen levels, and PCOS a condition of low estrogen levels.  What gives?


There are two ways to answer this question.  First, PCOS patients can have high estrogen levels, and in fact many of us do.  For this reason, you can have both endometriosis and PCOS without rocking the boat of your theory.   On the other hand, I also believe it is entirely possible to have endometriosis and to have low estrogen levels.  This is because endometriosis and endometrial pain is related to high estrogen levels, but there are a variety of other factors in the development of endometriosis.  Having an impaired immune system and inflammation are two big ones on the list.  Once those things happen together, and you plant endometrial tissue somewhere in your abdomen (and in all likelihood aided by having high estrogen levels), then you have endometrial tissue that is going to be very difficult to weaken.  That is just the nature of the tissue.  It does not just shed off effortlessly.   In this time period your estrogen levels can drop and your immune system can improve, but your tissue may still cause you pain.  This is how you can have low estrogen and endometriosis.  The solution is to mitigate the problems as best you can, reducing stress and inflammation, healing your gut, boosting your immune system, and eating a hormone balancing diet such as the paleo diet.

I wrote about endometriosis at great length here.


I stumbled upon your website researching the Paleo lifestyle and was pleasantly surprised to see the tie in to PCOS! I’m sure you’re wondering why I’m commenting on this article but being an avid consumer of marijuana, I had to click and read. Admittedly, I was quite disappointed in what I read not about marijuana but more about seeds, nuts and quinoa. I was under the impression that quinoa was NOT a grain but rather a seed. I’ve successfully omitted all grains, beans, soya from my diet and this was a major bummer to read.  I am feeling very deprived right now thinking of the possibility of having to omit this as well. Thank you for the great article however and keep up the great work.


Quinoa is in fact not a grain.  It is called a “psuedo cereal” because it does not come from grains or grasses, but is rather the seed of a plant.  It is gluten free.  That being said, it also has many properties that seeds do, such as having a relatively high amount of phytoestrogen content (and will contain many of the phytates inherent to legumes, beans, and grains all).  Phytates are also a bit of a problem for PCOS because they have the potential to limit calcium and magnesium absorption– two ions quite crucial for the development of healthy and fertile corpus lutea.  All of which is to say that seeds are not great for PCOS, but unless you are eating buckets they will not make or break your case.  Probably, at least, in my opinion.

My thoughts about restriction are of course always complicated.  If quinoa is something that is necessary for you to feel good about food and your body, then I advocate keeping it in your diet at least for a while.  Clean up as much as you can, and relax into your food choices.  Try eating less whenever it seems easy to do so.  If it’s a battle, don’t fight it.  Just phase it out only as you can let it go with peace.  This will happen over time with patience and with love.  And if it does not, I really think that’s okay, too.  Take care of your brain first and foremost.   It is going to be your most important tool by far for taking care of your body for the rest of your life.


I have question. I had a hysterectomy in May 2012. I struggle with endometriosis, hashimoto’s, Sjögren’s syndrome & celiac. I’m on estrogen therapy & the autoimmune protocol but my allergies are getting worse! I eat meat, non starchy vegetables & fruit. I can’t tolerate any spices or starches & my allergies continue to worsen. Any suggestions?


You may wish to try eating a GAPS diet to heal your gut further.   Allergies are not my specialty– but I highly recommend first doing everything you can to assist your immune system, since this is where allergy problems are rooted.  This includes reducing stress, getting as much sunlight and/or vitamin D as possible, eating organ meat often–I’d advocate at least once each week–getting as much sleep as possible, and potentially getting your micronutrient levels checked to see if you have any deficiencies that are hindering immune function.    Boosting immune function will help your immune system react appropriately to foods without leaping into panic mode.  It also depends very much on what your allergies are and how you are reacting to them.   Are they definitely allergic reactions, or are they food intolerances?  This is a crucial difference.  An allergy is rooted more in immune issues and food intolerance is rooted more in the gut.  Allergen-specializing docs are probably the best place to go for troubleshooting this sort of issue.   You also want to make sure you are taking care of your hypothyroidism appropriately — are you supplementing with thyroid hormone?  because with Hashimoto’s you may need to be, so speak with your doctor about it — because thyroid hormone is crucial for immune function, for cellular repair, for probably energy usage, and just about everything else cells do.


I have had HA since february, since I stopped taking the birth pill. I am really underweight (5’10 and 100#). I lost a lot of weight when I started crossfit and doing a low-carb diet for two years. I am now trying to conceive.   My hormone levels are all very low.  I haven’t worked out for several months.   I only walk daily for one hour. I started seeing a therapist about my anxiety, who is helping me gain weight.   She makes me track my calories in order to gain weight. I have to eat more than 2,000 calories but rarely go over.  I am a bit scared of carbs.  Gaining weight is not working although I eat more and stopped working out. I keep counting the carbs and feel bad having potato chips and a cookie (too much carbs).   I do eat a good amount of fat (teaspoons of coconut oil, nut butter bacon, greek yogurt etc…).   What should I do?


Since your primary concern– and biggest obstacle– in getting pregnant is convincing your body that you are fed, you want to err on the side of eating more rather than less.  This should be the case all of the time.  Also, I recommend that you eat whatever you want.  Anything you want. I personally eat a very high carobhydrate for extended periods of time to zero ill effect. Do your absolute best to stay within the range of non-toxic foods (ie, skip the gluten, deep fried foods) and eat heartily. The more frequently you can hit your 2000 mark, or even better, go over, and the less you obsess, the faster you’ll regain hypothalamic health.

I cannot stress to you how much all of the factors of relaxing, reducing your anxiety, and gaining weight are all important for your ability to conceive.  This takes a lot of work.  You are going to have to have patience, and to forgive yourself as much as possible for all of the difficulty you are having moving forward.  The thing is that it is not your fault.  You have become inordinately thin as a result of psychological pressures put on you by an external environment, and now you are stuck with fighting that.  Keep your chin up and move forward as lovingly as possible.  Accept yourself as a natural body with natural needs.   When you look in the mirror, don’t obsess.  As a matter of fact, don’t look in the mirror.  It is way too easy to start seeing ourselves as bigger than we used to be– and even while we need to gain weight to be and even look healthier, by the simple fact of being “bigger” we think we look huge.  Don’t let your brain trick you into such radical subjectivity.   Do your best to put your evolutionary need and your fertility at the front of your mind, and be excited when you see yourself put on a bit of weight.  Do it slowly and make sure to protect your brain in all of this, but embrace your needs.  You are a woman with some strong ovaries and the power to carry children.  Nourish yourself as your body is crying out for, and take as much pride in that as possible.   Being thin doesn’t make you worthy.  Being a badass and tackling these problems with as much love and determination as possible does.

Eat carbohydrates!!!!  Carbohydrates a) do not make you overweight, they just don’t, period, and b) are supremely healthful for you, especially in a state of metabolic distress.   Start eating them slowly and learn bit by bit the lessons I am telling you.  You will see that they make you feel and look better without making you balloon in some ridiculous fashion.  They are just food, same as fat and protein.  Period.  Eat them whenever, however, and however much of them as you want.

Be patient, however, love.  These things can take time depending on how much damage has been done and how diligent you are about allowing some weight gain and calorie intake.   Increase what you are doing as much as possible, and make sure that you are erring on the side of nourishing yourself more rather than less.  Believe it or not you have already made radical progress.   You have started therapy– something most women never do!– and you have admitted that you need to work on some of these issues.  And you have really cut back on your exercise, and you are working on eating more and gaining weight.  These are all awesome things.  You are doing it, and you have so much to be proud of moving forward.  You will get there, especially with love, forgiveness, and harmony with your natural body on your side.




You can read more about my work and opinions and plans for PCOS in the manual PCOS Unlocked.

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Ask Stefani: PCOS Edition, and Cyber Monday Part II!

Posted by on Dec 17, 2012 in Blog, PCOS | 6 comments

Ask Stefani: PCOS Edition, and Cyber Monday Part II!

Due to a lovely letter and set of questions I received from a reader last week, I have decided to respond to a set of reader questions about anything on a bi-weekly basis.  These questions will also occasionally be devoted specifically to PCOS.   Today is the first of the series, huzzah!

I have also decided to run Cyber Monday back again!  From 9AM EST Monday morning (this December 17) until noon EST (December 18) PCOS Unlocked: The Manual will be available for half off the half off!   How enormously fun. !

How to get the discount:

Go to the PCOS Unlocked page.  Scroll all the way down to the bottom of the page where you can purchase it beneath the title “for discounts.”  Enter “december2012″ into the discount box, and away you go!




And here we go!


1) I lost my period at about 8 stone 10 pounds. I am 5’5.

Over the many years I have suffered form HA I regained my period on quite a few occasions – sometimes for a few cycles. Previously it was always at that weight that I regained it – and then, like a fool, I would try to lose a few pounds. However, I stopped getting it at that weight nearly two years ago – and I have since gained more weight (I have been 9 stone for nearly 6 months) and I still don’t have my period back.

Is it possible that every time you have your period, and then lose it, your ‘set weight’ at which you get your period back increases? Or do you think it is more to do with the diet I am currently eating/ have eaten before?


In my opinion, the best way to think about amenorrhea is to think of it as an algebra equation.  Remember from the 8th grade chalkboard?


 aX + bY + cZ + … = Result


Think of X, Y, and Z as variables that affect amenorrhea.  X could be weight status, Y could be phytoestrogen intake, Z could be your stress level… other variables might be genetic predispositions, ovarian health, different hormone levels, how much you exercise, what you eat, your micronutrient levels, your degree of sexual activity, your age, whether or not you’ve born children… everything.

Then a, b, c, the multiplying factors, would be how important each of those factors are, and how strongly they are present in your body at any given point in time.  With an enormous value at b, you may not have any problems at all save for stress.  Or perhaps your stress levels are moderate, but your insulin resistance is moderate, so those two factors coupled together increase your “Result” enough to push it over the edge into amenorrhea.

I find it plausible that as you stress your system more and more, your body requires more and more “help” from other areas in order to have optimal fertility.   This does not mean that your set point is increasing– it may be, but I could not ever say for sure– but it does at least mean certainly that variables and stressors on your body are changing shape.   Diet is certainly important– but that depends entirely upon what you are eating at any given point in time.  Keep the toxins out, eat whole foods, get plenty of calories in all of the macronutrient categories, repeat.


2) Coffee. I am loathe to give it up, and I have mensturated in the past whilst drinking. However, I will stop if this is a big issue. I can’t see any reference to coffee in the manual. Do you have an opinion?


Excellent question!  I do have an opinion.  I would refer you again to the equation I described above.  You may have menstruated while drinking coffee in the past, but perhaps coffee has always been a stressor on your body and you were just able to overcome it at that point in time.  Now it may be a stressor that your body is not capable of bearing.  I would call this a legitimate concern for women who struggle with stress and adrenal health.  If you think your PCOS problems are related to stress, I would consider cutting the coffee.  Or at least reducing the intake and seeing if it helps.  Coffee has the potential to wreak some very serious havoc on our stress responses (really it prevents the body from calming down) and that can disrupt the HPA (hypothalamic pituitary adrenal) axis.  With a dysfunctioning adrenal gland, the hypothalamus and pituitary glands can go off the rails as well.

That said, some women handle both coffee and stress quite well.  It’s an issue of individuality.  I will say however that I believe it is worthwhile to experiment with removing the coffee, simultaneous with increasing your sleep quality and duration, and doing as much stress reduction as possible.

3)  This question is a bit more random – but one Im really interested in.

I am currently married and met my husband a few years ago. When we first got together I began mensturating regularly, although I had suffered with HA before. I also gained a bit of weight so that I was about 8.5 stone, instead of 8. I mensturated for a few months and then lost a bit of weight and lost my period.   I have experienced periods ONLY after instances in which I was quite happy about and excited with my sexual situation. I would also regain my periods after shortlived affairs during periods where I was single.

I do realise many factors that come into play; when I engaged in happy sexual activity I would often eat heavily the next day. However I have also done this without getting my period back. I also appreciate that it may be that oestrogen levels peal and I, in turn, become more attracted to people when happily sexual.

Have you ever heard of the theory that oestrogen levels are spiked by sexual attraction? I knew a girl with PCOS who didn’t mensturate, but when she started an affair she started to.

I’ve heard rumors of such things before and I like the theory.  A quick (quick!) search through some academic databases hasn’t yielded much, especially because you are asking about sexual attraction rather than sexual activity.

I have heard many anecdotes of women who have regained their periods after beginning to engage in regular sexual activity.  I consider this the best method for correcting hormone imbalances.

What these women have claimed to me is that “you lose it if you don’t use it” — or at least that it is true in their cases.  I haven’t been able to learn much about this scientifically.   I can guess, however, how the hormonal cascade might work — dopamine levels, oxytocin levels, and other happy molecules such as serotonin rise relative to baseline when engaged in sexual activity (perhaps to a degree even when just flirting or snuggling.)  In fact, it has been shown that snuggling has a very real effect on hormone levels: oxytocin is produced while cuddling and is also known in the popular press as the “cuddle hormone.”   So this increase in happiness with a sexual edge may very well be like giving your pituitary gland a hug.

Neurotransmitters such as dopamine and serotonin have not been well studied with regards to PCOS.  It has been proposed however that hormones such as LH rise due to the activity of excitatory neurotransmitters such as dopamine.  It stands to reason that when you are engaged in sexual attraction, flirtation, feelings of comfort, or feelings of excitement, your dopamine and other excitatory neurotransmitter levels increase.  These, in turn, may help boost your pituitary function.

All of which is to say that these things– glands, brains, hormones– are still largely a mystery to us.  If you have found a pattern in your life, I suggest running with it.  Learn from it as much you can, and do your best to achieve that kind of happiness / pleasantness as much as possible.  If it’s good for your heart, chances are quite good that it’s good for your body.  Convincing your body you are in prime reproductive condition via regular sexual engagement doesn’t hurt, ever.

4) Over the past six months I have gained weight, stopped exercising and I think I am eating a very nutrient rich diet. I eat lots and lots of eggs, butter, liver and coconut oil. I also dont think I am very stressed. Since my period has not returned – and I am very light boned anyway – I feel like Im now getting stressed. At what stage might would you recommend going on birth control or HRT to protect bones?


That’s definitely something to talk with your doctor about– but I would say when your estrogen levels drop below what is typically established as “healthy” or “dangerous.”  That should be indicated on your blood tests, and OBGYNs generally know boatloads about estrogen and bone health standards.

That said, however, there are a wide variety of factors that go into bone health.  Also, if your estrogen levels are low only for a short period of time, you may want to discuss with your doctor the possibility that you continue to try naturally before working on the estrogen with HRT.   I would not stress about it, personally.  That’s largely because I wouldn’t stress about anything so long as I could avoid stressing.  Also this is a matter of personal opinion and understanding the risks.  What you need to know is that your risk for bone porosity increases as your estrogen levels decrease, but your general health and nutrient status is important, too, and short term fluctuations should be fairly well tolerated by most women.   It is also a risk happily born by some women.  I don’t recommend that, but I’m not recommending anything here.


5) The final loaded question, which is about calories.

I know it is a question of food quality and not so much of calories. But, like I said, I think I eat a really high quality diet. At 5’5 how many calories would you shoot for as a baseline? After years of undereating, and then a good few months of stuffing myself I think my leptin receptors might not be working that well. I think my metabolism may also be a bit out of whack so it is harder for me to just leave it to hunger or set weight. I can eat about 1200 calories per day and feel satisfied.

Do you have any very baseline calorie recommendations?


It’s interesting that you start with the statement “I know it’s a matter of quality more so than quantity…”  Because while that statement may have serious wisdom in it, calorie intake still is vital for women who are type II — that is, under metabolic stress — PCOS.

I understand your problem in calibrating your hunger and trying to figure out how much you should be eating.  It’s a struggle for anyone who has dealt with dieting, regimented eating, or even mindful eating in the past.  What I would say to you with regard to that is to always err on the side of eating more rather than less, and to never try and “go without” food.  If you think you might want to eat, you should eat.  Period!  :)

1200 is a very serious minimum for a woman who is 5’5 and recovering from an issue like Type II PCOS or Hypothalamic Amenorrhea.  I would shoot for 1500 at minimum, but honestly push something closer to 2000.  The important part is to not just “get by” but rather to be seriously satisfied.

Your metabolism very well may be a bit confused right now.  The way to heal that is to eat as intuitively as possible and continually give it as much fuel as it needs– forever.  Wild swings in under and over eating can cause weight flucutaitons, sure.  A constantly satisfying diet over a long period of time is the only way to assure your body that you are being fed.

You also mentioned a lot of nutrient dense foods, which is awesome.  Be sure that you are including some carbohydrate in there.  Carbohydrate is the most readily available energy source, and it also happens to be crucial for the production of thyroid hormone.  Start with a few pieces of fruit or servings of potato / rice each day and see if that helps you find a bit more balance.

As a quick final note, it is possible that you are finding yourself sated in that fasting sort of way on a ketogenic diet (if you happen to be on one), and therefore severely under-eating how many calories your body truly needs.  I speak with a lot of women who confess to eating very few calories but not feeling hungry on ketogenic diets, and then hating adding carbohydrates in their diet because they feel some hunger again.  That hunger, however, may be an important signal for a woman dealing with type II PCOS / starvation / hypothalamic amenorrhea.   (Honestly I think the claim that carbohydrates beget unreasonable hunger is itself more or less unreasonable, and at the very least a matter of personal context.)  Carbohydrate intake is a touchy issue for many people.  What I prefer to leave the conversation with, therefore, are a) the fact that many traditional cultures eat high percentages of carbohydrate with no apparent health defects relative to lower carbohydrate cultures, and also b) the notion that personal experimentation with our bodies and hearts is the most important thing for our health and happiness.  If you eat carbohydrates and find that your body works better, then they are probably for you.



I’d also really like to finish with the comment that I am willing to try anything   I listened to your podcast with Diane and Liz and your words about not over emphasising stress/ adrenal fatigue etc – because 75% of it is diet –  made so much sense to me.
I know exactly what you mean when you said you would ‘try anything before gaining weight’ – I used to be exactly like that, but I really am not anymore. Now I’m just confused. To kind of summarise I am now half a stone heavier than the weight Ive mensturated at, doing stuff like drinking coconut mlik from the can and no longer exercising. I don’t think I’m picking at the details any more and I would really just value your opinion so much. I have even considered losing a bit of weight – the healthy way! – and then trying to regain it, just to give my body a bit of a shock. Im worried though that would be just like going backwards.

Uh, right.  Don’t do that.  :)   Give your body some love and patience, and trust your body to heal itself.  Don’t panic about it.  Believe it or not, stress about this, even if it seems like it’s not all that much, really might be a significant factor for your physical health.  The fact that sexual attraction has played a role in your menstruation indicates to me that your HPA axis always benefits from some tender loving care.   Give yourself a few months and eat intuitively– you may drop weight naturally, or not, but I think you should be totally psyched about being 9 stone and 5’5– that’s a SEXY weight!– and see what happens.  Get yourself tested again and see if anything has improved.  If not, perhaps revisiting some tests and issues (such as hypothyroidism?) or vitamin supplements would be important at that point.

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Announcing PCOS Unlocked: The Manual: The First 50 go for 50!

Posted by on Oct 17, 2012 in Blog, PCOS | 12 comments

Announcing PCOS Unlocked: The Manual: The First 50 go for 50!

Today is the day!  PCOS Unlocked: The Manual is available.  I could not possibly be more excited.  This is important information, and I’ve finally got it in an accessible, digestible, comprehensive package.  Here we come, world!   We’re healing PCOS holistically, for all women with as many different hormone profiles that we can possibly conceive of.  I love this manual, and I think you will really love it, too.

And, both because I’m so geeked about this release, and also because my birthday is tomorrow and I am swimming in a pool of effusive love, the first 50 copies of the manual are half off!!   People started finding sneaky ways to buy them last night, so grab them while you can.  I’m hoping very much it’s PfW community members who get the half price editions.


So PCOS Unlocked is, essentially, my brain dump.  It’s everything I know about PCOS and hormones, and synthesized in an organized way.

PCOS Unlocked is a thorough explication of what PCOS is, and why you have it, and how to overcome it.

Most importantly, in my opinion, however, is that it takes into account all of the factors that go into causing PCOS.  Most medical professionals, alternative health practitioners, and authors of PCOS books only really account for insulin resistance as a cause, or focus on it to the point of exclusion of everything else.  However: insulin resistance is not the only problem.  Overweight is not the only problem.   Not even close.  Dietary and lifestyle problems abound.

So in PCOS Unlocked, I address those problems.  I share with you why and how they occur, and I teach you how to recognize them in yourself, both by looking at your diet and lifestyle and also by looking at your blood tests.  I help you understand the shape of your PCOS, and I guide you through the healing process.  I share with you the proper diet, but then I also describe specific strategies for eating and living that you might want to consider in light of which category of PCOS you fall into.

To do all of those things,

PCOS Unlocked contains:

The 130 page manual, detailing…
           What PCOS is
           Why you have PCOS: Including a breakdown of the three primary types of PCOS
           How to overcome your PCOS
An exploration of alternative treatments such as drugs, supplements, and herbs
The 7 supplemental self-empowered treatment guides
The Food Guide
The PCOS Type Summary Cheat Sheet
The Stress Checklist
The Hormone Glossary
The Type Specific Indicators Guide
The PCOS Typing Flow Chart
The Blood Test Interpretation Tables
24 audio tracks explaining everything in detail
Totalling 2.5 hours of instruction
10 video break down guides
More than an hour of breakdowns and instructions in dynamic form

See the table of contents here.

So purchase the manual if you think it’ll help inform your brain and your life!  I put many furrowed brows and beads of sweat and too late nights into the project the aim of doing so.  I’d like to think I succeeded.

I am of course receptive to your feedback, and excited to hear what you think, so please let me know in the comments here or via email at

It’s going up to 97 dollars as soon as we get to the 51st copy!  If you want one, grab it!



Or see it at it’s home, PCOS Unlocked: The Manual.


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Psychological stress and female hormones: a recipe for fertility disaster

Posted by on Oct 10, 2012 in Blog, Hormones, HPA axis, Mental Health, PCOS | 5 comments

Psychological stress and female hormones: a recipe for fertility disaster

While the title of this post may sound hyperbolic, it nonetheless is grounded in truth.  There are a wide variety of dietary and lifestyle factors that affect reproduction.  Stress may be one of the greatest of all.


Dozens of studies performed on cynomolgus monkeys, bonobos, chimps, and baboons have demonstrated that having low social status–even while maintaining the exact same diet at high social status individuals–induces impaired fertility in primates.     Human models, while approximations, do not differ.   In some, a simple progesterone-dampening effect occurs,  in others the levels decrease precipitously, in most cortisol levels skyrocket, but in general a wide spectrum of reproductive disorders- from hormone deficiency to full-blown long-term amenorrheic infertility- follow from psychological stress.  This is something about which I have written before, and it’s a serious problem, causing not just outright and obvious infertility but also sneakily impaired and sub-optimal fertility all across the country.


Pysychological stress wreaks all sorts of havoc on the body.  Most importantly, cortisol levels rise, and the body’s inflammatory and immune responses become impaired.  Blood sugar levels rise, and insulin levels rise, too.  When these things happen, healing cannot occur, and tissues become progressively damaged with time.  This applies to reproductive tissues as much as it does to the rest of them.   Hypercortisolemia is good for nobody.

Several hormone responses also occur.  Three of the primary ones are as follows:

1)  As I mentioned, due to elevated cortisol levels, insulin levels may rise, and testosterone levels rise right alongside it. This is because insulin directly stimulates testosterone production in the ovaries.  This is bad for reproduction because a proper balance between testosterone and female balance needs to be maintained in order for proper reproductive signalling and tissue development to occur.   One particularly potent way in which this imbalance often hurts women is in the hormone condition Poly Cystic Ovarian Syndrome.  It is not the only thing that contributes to PCOS– definitely not– but it can play a big time role in it.

2)  Moreover, another effect that may occur as a result of stress is an increase in production of DHEA-S, a hormone produced in the stress glands.   DHEA-S is, like all other hormones, an important and very healthful hormone in proper balance.  But if the stress glands are in overdrive, they might over-produce everything, including DHEA-S.  This is detrimental, because DHEA-S is also a classically male sex hormone, and it plays a role similar to testosterone in PCOS.  DHEA-S in excess blocks estrogen signaling, interferes with LH and FSH signaling, and also increases hormonal acne.  DHEA-S can play a role in both type I and type II PCOS.

3) Finally, the brain, via the hypothalamus, sometimes turns off pituitary activity in response to stress.  This often leads to a cessation of LH and FSH signaling–the two primary pituitary signalling molecules–which in turn decreases levels of estrogen and progesterone in the blood.  Recall that reduced progesterone levels are one of the primary markers of reproductive distress in primate studies.  Prolactin levels may also decrease.  These facts make it impossible both to ovulate and to menstruate.

*Graphic extracted from PCOS Unlocked: The Manual.


These three categories– testosterone elevation, DHEA-S elevation, and pituitary decreases may occur differently in all women.  And there are a wide variety of other, more subtle, hormonal responses that also occur, especially when considered in conjunction with all of the other bodily stress that follows from psychological woes.

All that being said, STRESS IS BAD.  We know some of the reasons why, as I’ve explained above.  Others likely exist.  Even if you don’t have infertility problems, you may have hormone imbalances or deficiencies, and those can be just as insidious.  Eat right, sleep right, live well, breath deeply.  Repeat.


Stress is a significant problem for women’s health, and particularly women’s hormonal health.  This is manifested in a wide array of problems, but also most predominantly these days in the condition PCOS, or Poly Cystic Ovarian Syndrome.

You can read more about stress and it’s interplay with cysts, as well as how to overcome it all,  in my forthcoming guide, PCOS Unlocked: The Manual.   Coming to this website on 10.17.12, ONE WEEK FROM TODAY.






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Hormonal Acne: Where It’s Coming From, and What to Do about It

Posted by on Jul 19, 2012 in Blog, Hormones, Hypothalamic Amenorrhea, PCOS | 141 comments

Hormonal Acne: Where It’s Coming From, and What to Do about It


One common trope in the paleosphere is that acne is caused by irritants to the gut lining and inflammation.   The idea is that food toxins create a permeable gut, which in turn permits toxins to enter the bloodstream and wreak havoc on our skin.   Several advocates have a good point when they say that “virtually everyone who has acne has a gut issue” — yet based on my own reading and experience I do not yet know if I can get 100 percent on board with that, having seen so many women’s acne cured by fixing their hormonal issues.  What I do know is that women experience acne at greater rates than men, that hormones can be significant contributors to acne, and that in women with any hint of hormone issues, hormones should be the first culprits targeted in the war against acne.   Guts should be attended to.  But there is only so much a healed gut can do when a woman’s hormones have jumped ship.

Hormonal Acne Presentation

When: Hormonal acne in many cases presents at certain times of the month.  Popular times include 1) at ovulation, which occurs ~week three of the cycle (which can be discerned by body temperature variations) (with the menstrual cycle starting on day one of blood flow), 2) the few days before a period, and 3) at the start of a woman’s period.  Cyclicity is not the only way acne manifests, however.  For women with hormonal problems such as PCOS and HA, hormonal acne can persist all of the time.

Appearance: Hormonal acne usually presents as cysts–which are those lovely, pus-filled, painful and inflamed sacks.  Hormonal acne may also present in more mild forms as comedones–those whitehead “bumps” that never break the surface–or even in some cases as smaller lesions that are not quite as angry and painful as full out cysts, and may appear more rash-like or just smaller than typical acne.

Location: And in terms of location, hormonal acne occurs first and foremost around the mouth: on the chin, below the nose, around the sides of the mouth, and sometimes up the jawline.  As hormonal acne worsens, however, it can spread to the cheeks and the forehead.   Other body parts can be affected, too, but only in severe cases, and once it has advanced.  If acne is presenting in locations on the body without being present around the mouth area, there’s a decent chance hormones are not the primary culprit.

The physiological mechanism of hormonal acne

Hormonal acne comes from up-regulation of oil production within the oil glands beneath the skin.  The glands become over-burdened by the oil when this happens–there’s just too much of it–and it erupts to the surface, having to simply “go somewhere.”

Inflammation can exacerbate this process.  The worse inflammation is, the more irritated the oil gland can become, and thus the more red, and the more painful.   Yet eruptions do not occur first without an oil problem.   This is the reason no amount of washing will ever clear up hormonal acne.  It comes from underneath.  The only way to fix it is with interventions in the bloodstream.

What causes increased oil secretion

In the case of hormonal acne, the primary drivers of oil secretion are androgens (male sex hormones), specifically when they are elevated relative to other hormones, particularly estrogen, in the blood.  When skin cells detect higher levels of androgens in the blood, their DNA responds by up-regulating oil production.

The most prominent androgen is testosterone.   Testosterone-driven acne is most obvious in women with PCOS, who often only find out they have PCOS once they experience acne and ask their primary care doctors or dermatologists about a cure.  Acne is one of the clearest indicators of PCOS and of the underlying hormonal imbalance for this reason.   This is also, interestingly, why men on steroids often experience acne around the mouth area.  Excess testosterone causes hormonal acne, plain and simple.

Yet it is not the only androgenic culprit.  Another androgen, called DHEA-S, causes acne production as well, though DHEA-S serves the female body less as a male sex hormone and more as a precursor hormone.  DHEA-S is produced primarily in the adrenal glands.   From there, DHEA-S acts as a building block for virtually all other hormones.  For this reason, HPA axis dysregulation is usually the first place to look to as the origin of DHEA-S problems.  Women with high stress levels, dysregulated HPA axes, or hypothalamic amenorrhea often experience increased DHEA-S levels.   Some women with PCOS do as well, depending on their etiology.  (See my post on the inter-related nature of HA and PCOS).  The presentation of elevated DHEA-S is less well-defined and understood than testosterone, but it is still crucial in understanding the relative balance between androgens and female sex hormones in the body.  Moreover, because it is produced by the adrenal glands, it speaks volumes to the amount of dysregulation and stress upon a woman’s HPA axis.  DHEA-S increases oil production when present in disproportionately high amounts.

Because hormonal balance is in large part what cells detect when determining how much androgen is floating in a woman’s bloodstream, low estrogen (relative to androgen levels) is also a significant driver of hormonal acne.   Estrogen has the power to off-set high testosterone levels in the blood.  This occurs via increased testosterone binding activity, which estrogen enables by increasing the activity of sex hormone binding globulin (SHBG).   For this reason, if low estrogen levels are restored–either in women with PCOS or HA or some mixture of the two–then testosterone levels are mediated and hormonal acne decreases.   Because hypothalamic amenorrhea often sends estrogen levels into the basement–particularly if a woman has low body fat levels–this is the primary mechanism by which women with hypothalamic amenorrhea cure their acne.   Because menopause significantly decreases estrogen levels, this is also the primary reason women in menopause can see a re-emergence of hormonal acne after decades of clear skin.

As a final cause, progesterone can also play a role in hormonal acne.  Progesterone, in high doses, acts as an inflammatory agent, and in this way causes acne to flare up.   Progesterone levels being highest during the days leading up to menstruation explains why many women experience outbreaks at this time.

Moreover, testosterone levels peak at ovulation, while estrogen levels simultaneously hit their low, which is why the other common time for women to experience cyclic breakouts is at the start of week three of their cycles.

Aggravators of hormonal acne

Stress: Stress plays an important role.  It acts as an inflammatory agent, especially if cortisol levels remain high for a long time, and then also if a woman then enters into adrenal fatigue, which triggers a chronically inflamed state.  Stress may also dysregulate DHEA-S production.   For this reason, stress is not necessarily the cause of hormonal acne, but does exacerbate it, and prevent proper healing.

Heat.  Heat is inflammatory, and also causes us to sweat, such that pores become clogged.

Inflammatory foods: grains, dairy, omega 6 vegetable oils.

Dairy: While being inflammatory, dairy is also the most androgenic of foods.   Pregnant cows produce a protein that inhibits normal testosterone processing in the human body, such that testosterone can rise beyond normal levels with high dairy intake.  This is true of women with pre-existing hormonal imbalances, yet it is also true of the general population.  Many people at least anecdotally least respond to dairy with acne more strongly than any other food.

Phytoestrogens: soy, flax, legumes and nuts in high quantities.   While phytoestrogens have the power to act as estrogens in the body, this role is ambivalent and should be treated with caution, especially with the skin.   Different estrogen receptors read different kinds of phytoestrogens differently, such taht phytoestrogens usually perform estrogen-lowering effects in skin tissue.

Low carbohydrate diets: Having sufficient glucose stores is important for skin healing, and can speed the recovery of acne lesions.  Glucose is also helpful for preventing hypothyroidism.

Poor sleep: Sleep both enables healing and promotes hormonal production (and as such helps restore hormonal rhythm and balance).

Hypothyroidism:  Without sufficient levels of T3, the active form of thyroid hormone, in the blood, a woman’s skin cells lack the ability to heal properly.  Many women who suffer hypothyroidism suffer chronic acne.

Dealing with hormonal acne

The way forward with hormonal acne is to get blood work done and work through the primary imbalances.  In general, hormone dysregulation that leads to acne can be broken down into a few categories: 1) high testosterone from PCOS (specifically overweight and insulin resistant PCOS), 2) low estrogen from low body fat levels, chronic restriction, or living in an energy deficit, 3) low estrogen from menopause, 4) high progesterone from general hormone imbalance, possibly as a result of an overactive pituitary and estrogen dominance, 5) any of these conditions worsened by stress or hypothyroidism, and 6) any combination therein.

The solution to all of these problems is to correct the hormone imbalance.  I have discussed methods of doing so above and elsewhere.  (See my posts on PCOS causes and treatment options, and some of my work on hypothalamic amenorrhea.) For most sufferers of hormonal acne, testosterone is elevated due to insulin resistance and PCOS.  The solution, then, is to eat an insulin sensitizing diet, to exercise, and to decrease stress.   For other sufferers, DHEA-S may be too high, so stress should be a big factor to examine.  And for many others, low estrogen relative to testosterone is the primary problem, and modes of increasing estrogen levels should be examined.  These include weight gain, stress reduction, and improved sleep quality.  For women with menopause, it may just “take time” or perhaps medical interventions are appropriate, depending on the severity of the problem.


There are drugs designed to help with hormonal acne.  Spironolactone and flutamide are the two primary ones that come to mind, as well as birth control.

The reason birth control pills are helpful for acne is because they enforce hormone regularity on a woman’s system.   The precise pill that is helpful for each woman varies by her particular condition– but in general, BCPs are comprised of estrogen and of progesterone.  BCPs can for that reason 1) raise estrogen levels–which either corrects an estrogen deficiency or helps balance the activity of runaway testosterone–and they can also 2) restore proper balance between estrogen and progesterone, which is important for keeping progesterone levels within their proper parameters.   Some BCPs also contain anti-androgenic substances, such as spironolactone, which is an added benefit for women who are living with androgen excess.  In all cases, I do not generally recommend that women get on BCP, as it can cause worse hormonal dysregulation in the long run (sort of like handicapping a delicate hormonal system), and does not solve the underlying problem.

Flutamide acts in a similar way to spironolactone, but less effectively, and with more side effects.   So spironolactone is typically the drug of choice.

Spiro has been hailed by many women as God’s gift to womankind.   For many women it begets truly miraculous effects.  Yet one should step cautiously with spironolactone.   If a woman’s primary problem is not testosterone excess, spironolactone will very likely do more harm for her skin than good.  (Check out the panicked discussion forums at to see what I’m talking about.)  Moreover, even for those who have testosterone excess as their primary problem, spironolactone merits caution for a variety of reasons.   First, spiro usually induces an infamous “initial breakout” which can last anywhere from weeks to months.  This isn’t always the case– sometimes women improve immediately.  Sometimes they never really do.   But the typical case is for women to see an initial worsening of their acne, followed by relief in the upcoming months, especially if they increase their dosages.   Secondly, spiro cannot be taken by pregnant women because it induces birth defects, so women cannot stay on spironolactone indefinitely.  This is problematic because spironolactone acts as a bandaid on the hormone problem, and does nothing to fix it whatsoever.  What spiro does simply is block testosterone receptors.  In a few cases, it cures women.  Yet in very many cases, if the underlying problem is not addressed while a woman is taking spironolactone, her acne will return once she comes off of the drug.   This is why I recommend that women only consider taking spironolactone if they want a “quick fix” while they work on their diet and exercise in order to improve their PCOS.  As a final note, spironolactone has a couple of other health concerns.  First, it lowers blood pressure, since spiro is actually a blood pressure lowering drug proscribed “off label” for acne.  Secondly, it acts as a diuretic, so women on it need to drink water constantly, and may not be able to consume alcohol anymore.  And finally, spiro acts as a potassium-sparing diuretic, such that women cannot eat potassium rich foods, lest they risk the chance of becoming hyperkalemic, which can–I swear to God–lead to sudden death.  It’ll probably lead to muscle weakness first, but an imbalance of electrolytes in the blood is no laughing matter, so women on spiro should limit their potassium rich foods as well as get their potassium levels checked periodically.  Potassium rich foods include bananas, potatoes, avocadoes, tomatoes, and leafy greens.

For these reasons, spiro can help, but it cannot be relied on long term.  It does not get at the root of the issue–drugs rarely do–and the true path to hormonal help is diet and lifestyle modifcation.

As a final note, bio-identical hormone supplementation can be helpful for women going through menopause.  Estrogen patches can release small amounts of hormone into the bloodstream, and can lessen acne considerably.   I do not think this is detrimental to a woman’s health, if it is in fact the case that her estrogen levels have simply dropped off during menopause.    However, it does, in my opinion, make it difficult for estrogen levels to rise and hormone balance to re-establish itself on its own.  This is a decision best left to the individual and to her doctor.

In conclusion

Hormonal acne is terrible, and for many women can seem incessant, and never ending.  Girls are assured growing up that they will eventually out-grow their acne, yet many women see it persist throughout their twenties and thirties, and some actually do not even see the acne manifest until their twenties and thirties.  Some women do not even see acne appear until after the birth of their first children, as their progesterone and estrogen levels are flying all over the map.

For this reason, drug interventions can serve as decent placeholders in moving forward.  It can help the pain and awkwardness of acne while diet and lifestyle fall better into place.   Yet there are downsides to medication, and large ones.  Medication is only ever a band-aid, and it can be a band-aid that in the long run leads to more harm than good.  One point I did not even touch on above is that playing with hormones is like playing with fire.  Sometimes things can go horribly wrong– on spironolactone and BCPs alike some women suffer weight loss or significant weight gain, increased acne, and significant–even frightening and life-threatening–mental health disturbances.  For this reason, meds may be best left alone, depending on the circumstance and the level of risk a woman is willing to bear.   On the other hand, there is in all cases a natural, food-based solution.  What it takes is time, experimentation, good blood work, and patience.  As in all things.


January 2014 Update: For an even more thorough blog post on the causes of acne and overcoming it, see the new post on acne, here.

For more information on hormones and hormone balance, see my book, Sexy by Natureat its site or read reviews and buy it directly from Amazon.

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PCOS and Hypothalamic Amenorrhea: what’s wrong with the contemporary understanding, and how women can have both

Posted by on Jul 3, 2012 in Blog, HPA axis, Hypothalamic Amenorrhea, PCOS | 62 comments

PCOS and Hypothalamic Amenorrhea: what’s wrong with the contemporary understanding, and how women can have both

PCOS is complicated.  It’s an easy diagnosis, but the causes of it are rarely understood.  This is because cysts crop up under a wide variety of hormonal circumstances.   We might think that this would mean that the medical community recognizes the need for diverse treatment among PCOS patients, but actually it does not.   Instead of considering the wide variety of PCOS needs, many doctors (especially those who are not endocrinologists) use blanket diagnoses and treatments for all of their PCOS patients.   This is not wholly unreasonable.  There is  a majority PCOS condition, and the biochemistry of this condition is both simple and compelling.  However, there remain other causes and problems.  Failing to address them means that thousands of women end up falling through the cracks.

The current understanding of PCOS is flawed in two major ways.   First is what I just described above, the fact that the wide array of different hormonal issues that might cause PCOS has not really been explored or emphasized.  Instead, PCOS is broadly regarded as a direct effect of being insulin resistant and overweight.  However, this only accounts for between 60-80 percent of PCOS patients.  The second flaw is a corollary of that nearsightedness: most members of the medical community (though there is a real debate getting off the ground) believe that it is impossible to have both PCOS and hypothalamic amenorrhea at the same time.

I disagree.

The belief in problem number two, ie, that HA and PCOS are incompatible, derives from the first problem, ie– the lack of a nuanced understanding of PCOS.  PCOS is widely regarded as a problem of insulin resistance and being overweight.  These are two significant factors that generate cystic ovaries.  But they are not the only ones.  Only 60 percent of PCOS patients are overweight.  Some normal weight PCOS patients are also insulin resistant.  Yet others still are not.  What causes normal weight women to develop cystic ovaries?  And what about insulin-sensitive women?

Recommendations for overcoming PCOS are directed at this insulin-resistant.    PCOS patients are advised by the National Institute of Health to “drop 5 percent of their body weight” in order to become fertile.  This is, again, great for the majority of PCOS patients, who usually do well and recover reproductive function with the simple implementation of an insulin-sensitized lifestyle.  This is why the paleo diet kicks ass for overweight women with PCOS.   When they exercise, eat low-ish carbohydrate diets and eliminate refined foods…. these women correct their insulin resistance, reduce their testosterone load, and as such watch their hormone balance fall elegantly in line.  It is worth noting that there are different nuances within this population– that some of them have vastly different estrogen and progesterone levels and varying degrees of hormonal imbalance.   This is another reason that a nuanced understanding of PCOS is necessary for the health of each women.  Nonetheless, however, overweight PCOS patients generally recover well on weight-loss and insulin-sensitizing programs.

This does not really do the trick, however, for the rest of the women out there with PCOS.

Below, I discuss the typical and some atypical causes of PCOS, which will hopefully shed light on a) the variety of ways in which hormones can be disrupted, but also in particular b) how hypothalamic amenorrhea (and hypothyroidism) can play a powerful role in causing cystic ovaries.


There are three characteristics necessary for a PCOS diagnosis for all women:

-Cystic ovaries, as detected via ultrasound

-Elevated androgen (male sex hormone) levels

-Irregular or absent menstruation

Overweight and insulin resistance are two important ways these characteristics can be brought about, yet other ways are equally powerful.   The thing is– having cystic ovaries means that the process of menstruation is not completed properly.   It does not mean necessarily that one universal step (such as insulin resistance) goes wrong.  Instead, it means that at some point along the chain throughout the four menstrual weeks, one or more factors misfires.  A signal is missed, one hormone floods the rest of them, or one hormone isn’t properly produced, for example.   Androgens usually end up at dominating the reproductive scene, and cysts usually develop.  But the mechanisms by which this occurs are not as simple as many PCOS practitioners would have us believe.

The dominant pathway by which women develop poly cystic ovaries is, again, that of the overweight woman.  It is a fairly simple process:

1) insulin stimulates testosterone production in the ovary, and

2) testosterone production throws off estrogen levels and inhibits estrogen signalling.

In PCOS, testosterone and estrogen become improperly balanced, and the rest of the menstrual cycle, which takes its cues from the rise and fall of estrogen levels, suffers.  LH and FSH, two pituitary hormones that tell the ovaries what to do and when, are of particular concern. LH and FSH levels become dysregulated with dysregulated estrogen because they take their cue from blood estrogen concentrations.  This is why the vast majority of PCOS patients have a reversed and high LH and FSH ratio compared to healthy women.   The pituitary gland keeps trying to make the body ovulate, but it does not read estrogen signals properly, and the ovaries do not hear the pituitary properly.   So these are the markers of the typical PCOS diagnosis: inverted LH and FSH, insulin resistance, overweight, and elevated testosterone levels.

Yet there are other means by which a woman’s hormonal profile can create cysts.


First is a simple case, and this one is thankfully recognized by many in the medical community: that of hypothyroidism.   Having low T3 (the active form of thyroid hormone) in the blood is strongly correlated with cystic ovaries.  When women with subclinical hypothyroidism correct their condition (this is normally done in medical studies by taking T3 pills), the majority of cases begin menstruating again.  This is presumably because low T3 levels decrease the activity of cells and hormonal signalling, which means that the menstrual cycle proceeds with fits and starts, rather than powerful, holistic health.   Three common causes of lower thyroid function are poor sleep, restricted calorie intake, and a long-term carbohydrate limited diet (since glucose is necessary for the conversion of T4 to T3 in the liver).


Second is the important and powerful case of hypothalamic amneorrhea.  HA is known by many to be exactly the opposite of PCOS.  In PCOS, hormone levels often skyrocket.  High testosterone, high and uneven LH to FSH ratio, high estrogen levels (though not always).  In HA, hormone levels plummet.  Low LH, low FSH, low estrogen, low testosterone.  PCOS is a problem of being overweight; HA is a problem of being underweight.  In PCOS, women over-produce hormones.  In HA, women under-produce hormones.

Or so the story goes.  However, women can present with cystic ovaries and still have low levels of hormones.  The problem– the real, truly universal problem that creates cysts–is a hormone imbalance.   Absolute levels of the hormones are important, but even more important is the balance between testosterone, estrogen, progesterone, and leptin, even.  The other factors– insulin resistance, LH and FSH inversion, and being overweight– they are not the only thing that can create an androgen-dominant cystic profile.

Hypothalamic amenorrhea is a problem of being too stressed, eating too few calories, exercising too much, and having too little body fat.  In essence, it is a condition caused by hypothalamic stress and down-regulation.  Hence the name.

The ways in which these four problems typically classed under a diagnosis of hypothalamic amenorrhea– the eating, the exercising, the stress, and the body fat– can cause cysts and/or co-occur with more classically PCOS-type symptoms are vast.  Here are a couple of examples:

-A woman is really stressed out by work and life.  While most of her hormone production plummets, her DHEA-S production (the top-of-the-food-chain hormone produced by the adrenal gland) skyrockets in response to HPA axis dysregulation.  DHEA-S is an androgen, and it influences the development of cystic ovaries if estrogen levels are not equally as high.

-A woman is fairly healthy but has slept poorly throughout her entire life.  This pushes her towards insulin resistance, but more than that it dys- and up-regulates her cortisol production.  Cortisol signals to the HPA axis to decrease pituitary activity, and it does so.   Her hormone levels all decrease.  This woman’s predisposition to insulin resistance coupled with adrenally-induced fluctuations triggers the development of ovarian cysts.

-A woman is stressed out via the typical HA pathways–caloric restriction, excess exercise, and stress–so her pituitary hormones decrease in potency.  Testosterone and estrogen levels are low but okay, and the woman is probably thin but may also be larger, depending on the degree of stress.  Nevertheless, this time it is progesterone that takes the largest hit from the stress (taking it’s cue from both estrogen and LH), and menstruation can never occur without sufficient progesterone levels.

-A woman has a tendency towards insulin resistance, and is overweight, and then loses weight.  While this corrects the insulin problem, the drop in estrogen levels she experiences from the weight loss (since estrogen is produced in fat cells) causes an imbalance in her predisposed-to-testosterone-production ovaries.

- Or a similar phenomenon occurs with leptin: In this case, a woman may be a bit insulin resistant, and therefore have a predisposition to testosterone production, but she does not test into a “dangerous”  testosterone zone.  Instead, her problem lies in the fact that she lost weight, and with it, she lost the potency of her leptin stores.   During puberty, each woman’s body adapts to whatever levels of estrogen and leptin she has circulating in her blood at the time (creating a bit of a leptin “set point”).  Later in life, one of these women loses weight.   As she loses weight, and, significantly, if she is restricting calories or exercising excessively, her leptin (and estrogen) levels drop.  The hypothalamus perceives this drop as an indication of a time of famine, and initiates a starvation response, primarily by decreasing the production of sex hormones.  In this woman’s case, therefore, estrogen is low, and testosterone may be low to high, depending on the degree of insulin resistance and ovarian malfunction, but LH and FSH are both also low.  She does not present with typical PCOS.  She is not over-producing hormones, but is, instead, under-producing.


All that said, these are some examples of how typical HA problems can cause the cystic condition that is typically associated solely with PCOS.   Stress, excess exercise, restricted macronutrient intake, restricted calories, and weight fluctuation can all contribute to cyst development.   Many of these situations can co-occur, and that totally depends on a woman’s genetics, epigenetics, lifestyle, and diet.


The problem with having a poorly-nuanced understanding of PCOS lies in the way in which blanket recommendations are made for women with PCOS or HA.  As a result of this mindset, I have been criticized for recommending that thin women with PCOS eat carbohdyrates.  This is because those who are criticizing me believe that PCOS is solely a result of insulin resistance.  I do not believe so.  I believe that many women with PCOS do not necessarily have a problem with insulin resistance, and even if they do, it can be compounded by factors that lie outside of that typical diagnosis.

I would, then, tentatively recommend that women who are overweight and insulin resistant follow the typical PCOS protocol and under-take insulin sensitizing steps.   On the other hand, I would tentatively recommend that potentially under-weight and overly-stressed women with PCOS consider eating more, possibly upping their carbohydrate intake, and exercising less.   Women with low thyroid would do well to correct that problem however they see fit.  This is, however, particular to the individual, so please do not take my musings about PCOS etiology and treatment as prescriptions.  At all.

The real recommendation, therefore, is to get a blood test (!), and to have discussions with your doctor about all of the possibilities that could be affecting your hormone levels.   With PCOS it is crucial to order blood tests.  While it is a near certainty that androgen levels are elevated relative to the rest of the hormones, that is not the case 100 percent of the time.  All of the hormone levels– testosterone, estrogen, progesterone, LH, FSH, and T3 levels may be all over the map and still cause a woman to present with PCOS.   An adequate picture of what is happening in the body is crucial for moving forward.  This then enables women to undertake dietary and lifestyle changes appropriate to their own holistic health and well-being needs.


For more information on PCOS, why you have it, and how to overcome it, check out PCOS Unlocked: The Manual, the multi-media resource I created in order to share all the PCOS information and experience I’ve amassed in my brain, and apply it to solving the unique case of your PCOS.



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