I spend a disproportionate amount of my time telling women to eat carbohydrates (read: “safe starches”–see below). The thing is, a low carbohydrate diet (<50g/day) can do wonderful things for people. This we all know well. It’s a quick way to lose weight, to sharpen insulin sensitivity, and to reduce appetite in the short term, and it can be hugely therapeutic for people with cancer, migraines,and chronic infections or psychological disorders.
On the other hand, low carbohydrate diets can be a significant tax on people, women especially.
Because low carbohydrate diets are so popular for weight loss, it is common for women trying to lose weight and to “look good” to exercise often, eat very few carbohydrates, fast, and restrict food intake. The more of these restrictions a woman undertakes at once, the more and more her body reads this as living in a starved, stressed state. The results are significant. Her adrenals fire heavily, her liver gets tired from performing so much gluconeogenesis, her insulin sensitivity drops, her body fat levels fluctuate, her leptin signalling gets off, she stops sleeping soundly, and she stops menstruating regularly.
I cannot say that this applies to everyone. Many women undertake low-carb diets–Peggy the Primal Parent comes to mind as a fierce advocate (recently, however, she has, in her own words “scrutinized” and weighed evidence against the diet)–and feel great energy, life, and liberation from symptoms of their previous lifestyles. But women who are experiencing low-thyroid symptoms, menstrual dysregulation, sleep and or mood and mental health related issues may find significant relief from adding carbohydrates back into their diets.
-Glucose is necessary for the conversion of T4 to T3 in the liver. Certainly, the liver is capable of producing its own glucose with gluconeogenesis, but that process can become taxed over time, particularly if the woman’s liver is already taxed from poor eating habits in the past, mineral deficiencies, stress, or caloric restriction. Instead, when a woman ingests glucose, she assures that her liver does not have to work overtime. She provides the glucose that her brain needs, rather than forcing her body to make its on its own. This helps the body function more efficiently and with less stress in general, but it also specifically optimizes thyroid activity. Hypothyroidism is implicated in mood disorders, reproductive irregularities such as PCOS and amenorrhea, in skin conditions, and in weight gain, among other things. Many women, contrary to popular paleo belief, in fact lose weight once they add carbohydrates back into their diets.
This is true of clinical hypothyroidism, as well as sub-clinical hypothyroidism. Note that in many studies, women with cystic ovaries and sublicinical hypothyroidism see the resumption of regular ovulation when they correct their thyroid issues.
-Glucose elicits an insulin response, which in turn spikes leptin levels in the blood. This is a short-term spike, so eating carbohydrates should not be used as a replacement for body fat, which is the primary long-term secretor of leptin. However, moderate, regular consumption of carbohydrate spikes leptin frequently enough to help signal to the hypothalamus that the body is being fed. Recall that leptin is absolutely crucial for reproductive function. Without leptin, the hypothalamus does not tell the pituitary to produce sex hormones. At all.
-Moderate carbohydrate intake is associated with better mood, stress-reduction, and sleep, pretty well across the board. I see this in my work and in anecdotes, as well as in many controlled studies. The carbohydrate-well-being connection also plays out decently in biochemical theory. Carbohydrate intake (via insulin and albumin) boosts tryptophan levels in the brain, and tryptophan is the protein precursor to serotonin. Presumably, then, carbohydrate intake helps with the vast array of issues associated with serotonin deficiency which include moodiness, stress, and insomnia. For a look at the details and complexities of the issue, see Emily Deans here and here. The primary takeaway of this point being that while the exact mechanism of carbohydrates boosting mood and sleep quality is unknown, carbohydrates still appear to be a healthy, and in many cases necessary, macronutrient.
The whole point being that carbohydrates are not just okay but important. For women who have appetite control problems, sugar addictions, and a lot of weight to lose, absolutely I believe a low-carbohydrate diet can do them wonders. For women who struggle with menstruation, fertility, stress, exercise performance, or stress, along with any other hormonal oddities, carbohydrates help assure the woman’s body that she is healthy and fed. This is crucial for reproductive health.
In all cases, diet is a matter of personal physiology and experimentation. If a woman’s body works better on carbs, she should eat them, and delight in those joys rather than worry needlessly. At the very least, they are not harmful, and at their best, they are life saving.
Carbohydrates to eat:
I recommend glucose-containing carbohydrates rather than fructose for a wide variety of reasons, least of which are appetite control, liver function, and the prevention of metabolic syndrome. Many studies seem to be indicating that fructose is the real culprit in all of these problems. Glucose, on the other hand, when eaten absent of fructose has real satiating power.
I also recommend starchy glucose, since it is a “complex carbohydrate” and is broken down more slowly during digestion, which prevents blood sugar from rising or dropping too sharply.
Of course, grain-based carbohydrates are a no.
Finally, I recommend carbohydrates that contain nutrients over empty carbohydrates.
This means that I recommend eating:
Starchy tubers such as sweet potatoes, batata, jerusalem artichoke, cassava, tarot, and bamboo. Regular potatoes are fine, too, but they contain fewer vitamins than their sweet counterparts. Of the sweet potatoes, Japanese sweet potatoes are the most delicious, in my opinion, followed by white sweet potatoes and then yams and regular orange sweet potatoes.
For fruits, I recommend berries and cherries, which contain more glucose than fructose, and also bananas, which are pure 100 calorie glucose bombs.
Both white and brown rice are fine, but are fairly nutrient-poor. Brown rice contains anti-nutrients in it’s shell, so white rice is more innocuous in terms of nutrient absorption.
Vegetables of course are great, but they do not count for carbohydrate consumption. I know that much of carbohydrate content is indeed processed as glucose, but much of it is also tied up in fiber, which is broken down and turned into short-chain fatty acids by gut bacteria. For this reason, vegetables alone cannot make up a woman’s carbohydrate consumption. Instead, starchy tubers and low-fructose fruits work the best.
How much to eat:
For a woman recovering from stress, metabolic distress, and hypothalamic amenorrhea, I recommend eating between 100-200 g/day. That goes for athletes as well. And for pregnant women. At least 100 g/day.
Moreover, carbohydrates taken later in the day help with insulin sensitivity (since that gives the body the longest amount of time throughout a 24 hour period to operate at low insulin and leptin levels). They also, anecdotally, help put people to sleep.
Carbohydrates elsewhere in the paleo blogosphere:
Chris Kresser and Chris Masterjohn: Cholesterol, mostly, also: Telltale signs you need more carbs
Jimmy Moore: Is there any such thing as a safe starch?
Jamie Scott: A Week of It
Paul Jaminet: Higher Carb Dieting Pros and Cons (includes a discussion of the “longevity trade-off”)
Cheeseslave: Why I ditched low carb
Beth Mazur: Why I don’t eat low carb
Julianne Taylor: Okay, People, Carb’s Don’t Kill
Melissa McEwen (always a badass on women and fertility): What the bleep do we know about carbs
While you’re at it, go read Melissa’s post on Why Women Need Fat. Now.Read More
The overwhelming majority of women with PCOS who undertake a paleo diet see great, quick results. The paleo diet helps them achieve greater weight loss, insulin sensitivity, and reproductive function. Paleo reduces inflammation and meets nutritional requirements, as well as balances hormones. When enacted properly, a paleo-type diet completely eliminates toxic foods from a woman’s body. Of course she is going to get better.
Unfortunately, I also know of a fair number of women who only begin showing symptoms of PCOS when they begin eating a paleo-type diet. Others have see their symptoms worsen. In response, I always wonder if these women have had some sort of underlying problem for a long time, perhaps via exposure to phytoestrogens or endocrine disruptors. The fact remains that a paleo diet sometimes exacerbates PCOS problems. What gives?
First, the biggest player in this problem is probably weight loss. As I mentioned in my post on PCOS etiology, shifting fat mass levels can alter the amount of estrogen in a woman’s system. If a woman was overweight as a child, if she began her period early, if she had a lot of leptin in her system as a child from eating a high carbohydrate diet, she may have trouble ovulating later in life at a lower, “healthier” BMI. The opposite is also true. This is unfair, especially in a world in which women are expected to look a certain way in order to be beautiful.
Secondly, many assert that weight lifting shifts the body towards great androgen production. Greater muscle mass = more testosterone? According to weight lifting gurus at least, yes. This means that the whole “strong is the new skinny” mantra may shift women’s hormone profiles farther than they can handle (especially with respect to the point I made above that a woman’s hormone levels are established early in life.) Additionally, an obsession with exercise may push a woman into an energy deficit, such that her ability to signal fertility from her fat cells to her hypothalamus is impaired. I covered this extensively when I talked about exercise-induced hypothalamic amenorrhea.
Third, paleo typically decreases leptin levels for a variety of reasons: 1) women eating a paleo diet often thin out naturally, 2) appetite is decreased so women eat less frequently, and 3) most people on paleo diets eat fewer carbohydrates. With less leptin in a woman’s body,signalling to the hypothalamus and to the pituitary glands is hampered. Sometimes it decreases enough to cause hypothalamic amenorrhea, which I treat at length.
Fourth, different kinds of paleo diets influence hormone profiles in different ways. For example, a diet heavy in nuts delivers to a woman’s system both excess phytoestrogens as well as a lot of omega 6 poly-unsaturated fats. These PUFA fats actually increase systemic inflammation rather than decrease it, and phytoestrogens throw off a woman’s estrogen production. Another example: dairy is testosterogenic. Many people give up dairy on a paleo diet, but others end up eating a lot of dairy, particularly butter. Butter, and its purified form, ghee, have been touted as a solution to the problem of food allergies by being free of casein and lactose, the typical proteins that cause digestive problems. Yet all dairy, regardless of the type remains testosterogenic: pregnant cows produce a protein that inhibits normal testosterone blocking procedures in a human body. This fact is why many people experience acne when they eat dairy.
Fifth, many people on paleo diets eat high protein diets. This is not optimal for longevity, nor for reducing cysts on the ovaries. Protein is a building block molecule, and if the body has already used enough bricks, it will redirect the remaining bricks to unnecessary locations. Cysts are one such example of this. Tumors are another. Another reason a high protein diet may not be ideal is that high protein diets increase levels of Insulin-like Growth Factor-1 in the blood. IGF-1 decreases Sex Hormone Binding Globulin levels in the blood, and SHBG is responsible for finding free testosterone. Most women with high androgen levels have correspondingly low SHBG levels. I recommend .5 grams of protein per pound of lean body weight each day. This means that a 100 pound woman would eat 50 grams of protein each day. She can go as high as 100 grams if she likes, especially if she exercises a lot (in that case it should be increased), but that may not be optimal.
Sixth, low carbohydrate diets can contribute to PCOS, though this is a complicated issue since all of the women with PCOS have such different etiologies. For example, overweight women with PCOS almost always see great benefits with a low carbohydrate (specifically fructose) diet. Yet for thin women with PCOS, low carbohydrate diets are problematic. Glucose is required for the conversion of T4 into T3 in the liver. Without glucose, T3 is not produced. Worse still, reverse T3 is produced instead, and reverse T3 acts as a T3 antagonist. So without carbohydrates, a woman’s thyroid activity can drop off dramatically. Hypothyroidism is one of the biggest causes of cystic ovaries, as well as general female malaise. Additionally, SHBG levels increase with an increase in thyroid hormone.
Finally, women on paleo diets are often perfectionists. They are sometimes orthorexic, and they stress out about their food, exercise, and bodies more than they ever have a right or reason to. Stress inhibits pituitary function, and in a very big way.
All that said, these are some of the ways in which a paleo diet and life style can contribute to PCOS. Much of it is related, in what I consider a “perfect storm” of endocrine problems. Yet without taking the diet to these extremes, and especially stressful extremes, eliminating toxins, eating natural foods, and living a stress-minimizing life almost always does nothing but wonders for women.
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.
What you can do to treat your PCOS
Please refer to my exploration of the causes of PCOS for a description of PCOS pathologies. What follows is a brief layout of different treatments. Going through them all, and experimenting and finding what works best, and talking to your doctor and doing your own research is all critical. This is just what I have found, both on the web and in my body. Note that the section on diet does not stand alone. There is more information on the role different foods play in PCOS is in the post to which I just linked.
If you are an overweight PCOS patient, I recommend that you eat low carbohydrate (specifically fructose) to decrease insulin and testosterone levels. Try and stick to glucose and safe starches when you do eat carbohydrates. These include potatoes, sweet potatoes, yams, and white rice. Fixing the metabolic syndrome that may be the causative root of your PCOS is a bit more complicated than this, but people seem to have success with this method across the board. Low carbohydrate diets tend to mitigate insulin signalling problems, which in turn helps with PCOS.
If you are an overweight PCOS patient, also, try fasting. Fasting, especially for people with overburdened metabolisms who are trying to lose weight, increases insulin sensitivity and helps the weight slide off.
If you are a thin PCOS patient, eat high carbohydrate. Carbohydrates elicit a greater leptin response than fat. Leptin is responsible for telling your hypothalamus that you are well fed. If you are someone who often feels hungry or who recently lost weight, you may want to seriously consider this idea. If your body thinks it is starving, it will not perform reproductive functions.
Similarly, if you are a thin PCOS patient, do not fast. Fasting decreases leptin levels.
If you are a hypothyroid PCOS patient, eat a high carbohydrate diet, at least 50 percent of calories, a la Ray Peat, Chris Kresser and PHD. This is because glucose is necessary for the conversion of T4 into T3 in the liver. Without glucose, less T3 is synthesized, such that many cellular functions, such as reproduction, slow down.
Don’t eat fructose. For overweight PCOS patients, fructose can inhibit leptin signalling and make you hungrier. Fructose is significantly, insidiously implicated in weight gain. For thin PCOS patients, fructose directly inhibits the reception of leptin in the hypothalamus. This is another factor that makes it difficult for the body to perceive whether or not it is being fed.
Don’t eat soy. Soy is the most potent phytoestrogen. Not only does soy beget PCOS by hindering the production of true estrogen, but it is also implicated in reproductive cancers.
Don’t eat legumes, which also contain phytoestrogens. This means all forms of beans and peas.
Don’t eat dairy. It’s androgenic. Having too many androgens in the bloodstream is one of the primary drivers of PCOS.
Lower the amount of cruciferous vegetables you eat (if you eat them a lot). Brassica plants activate an enzyme (cytochrome P450 enzyme CYP1A2) in the liver which clears estrogen out of the body. Additionally, if cruciferous vegetables are consumed often in the raw form, they act as goitrogens and can decrease thyroid function.
Eat plenty of fat. Fat is crucial for the production of hormones. And cholesterol. Cholesterol is one of the root molecules in endocrine production. Good fats to focus on are the monosaturated fats–olive oil, avocado, and macadamia oil–and saturated fat in the form of coconut oil or organic animal products.
Steer clear of Omega 6 PUFAs. Omega 6 fats are associated with increased testosterone levels in both women and men, in addition to causing excessive inflammation. This means limiting soy, canola, rapeseed, vegetable, and corn oils. Nuts in their natural form should also be avoided because they are primarily omega 6 fats, and also because they contain phytoestrogens.
Eat grapefruit. Grapefruit inhibits the enzyme CYP1A2 I mentioned above that clears estrogen out of the body. This is a nice trick to increase estrogen levels, but note also that it is not a permanent fix, and that the activity of enzyme CYP1A2 is still crucial for your health.
Eat magnesium rich foods to increase insulin sensitivity.
Eat beta carotene containing foods to increase progesterone levels. The corpus luteum has the highest concentration of beta-carotene of any organ in the body, suggesting that this nutrient plays an important role in reproductive processes.
Eat foods good for the liver. The best are high in choline, such as eggs and organs.
Eat organic meat or wild game, not factory farmed meat, as often as possible. The hormone levels are guaranteed to be natural and to disrupt your system as little as possible.
Drink spearmint tea. It’s fairly highly regarded as a testosterone blocker.
Honestly, in my personal experience, I have rarely witnessed benefits from supplements. In fact, the biggest changes I experience are usually negative and from overdoses, probably because I eat a rich enough diet already. So if you eat a range of vegetable and animal products, supplementation should not be too much of an issue. If you want to supplement for general health, I recommend checking out the Jaminet’s list of supplementation in their book, or which can be figured out over at their blog. Please use the organic (that is, carbon-based), chelated forms of any mineral supplements you take. Magnesium oxide, for example, is something you do not want to take because it’s basically eating crunched up metals. Instead, take a form of magnesium that is “bio-available,” or “chelated,” which means that it is a part of a molecule your body can actually use.
Supplementation to correct specific deficiencies, however, can be very helpful. If you’re worried specifically about your ovaries and your fertility, here is a list of supplements I have witnessed being efficacious:
On his podcast, Robb Wolf recommends that women with PCOS or androgen-dominant type symptoms try to boost their thyroid functioning with iodine supplementation. His clients are apparently satisfied and ‘healed’ by taking iodine. If you really suspect your thyroid in your pathology, however, I recommend getting your blood tested for levels of TSH, T3, and T4 at least before proceeding. Iodine can help with hypothyroid, especially if its an iodine deficiency causing the problem, but iodine can also hinder thyroid functioning in clinical hypothyroid cases, especially if the underlying problem is the autoimmune disease Hashimoto’s thyroiditis rather than a simple iodine deficiency.
Chromium helps to encourage the formation of glucose tolerance factor which is a substance released by the liver and which is required to make insulin more efficient. A deficiency of chromium can lead to insulin resistance. Because of this, it is the most widely researched mineral used in the treatment of overweight.
Selenium is crucial for thyroid functioning. Try eating one or two brazil nuts each day– they are supposed to be better supplements than the pills themselves.
Vitamins B2, B3, B5 and B6 are particularly useful for controlling weight, and here’s why: Vitamin B2 helps to turn fat, sugar and protein into energy. B3 is a component of the glucose tolerance factor (GTF), which is released every time blood sugar rises, and vitamin B3 helps to keep the levels in balance. Vitamin B5 has been shown to help with weight loss because it helps to control fat metabolism. B6 is also important for maintaining hormone balance and, together with B2 and B3, is necessary for normal thyroid hormone production. Any deficiencies in these vitamins can affect thyroid function and consequently affect the metabolism.
The B vitamins are also essential for the liver to convert your ‘old’ hormones into harmless substances which can then be excreted from the body.
Unfortunately, because our soil has been depleted by overfarming, there is very little natural zinc found in our food. Furthermore, processing and refining strip out what little might be remaining. So no matter how good your diet, you may not be getting anywhere near the levels of zinc that you need. There are two approaches to this: you can eat whole organic food, which has much more rigorous controls on farming methods, or you can add a zinc supplement to your diet. But why is it so important?
Zinc is an important mineral for appetite control and a deficiency can cause a loss of taste and smell, creating a need for stronger-tasting foods. Zinc is necessary for the correct action of many hormones, including insulin, so it is extremely important in balancing blood sugar. It also functions together with vitamins A and E in the manufacture of thyroid hormone.
Magnesium levels have been found to be low in people with diabetes and there is a strong link between magnesium deficiency and insulin resistance.
This is a vitamin-like substance that is contained in nearly every cell of your body. It is important for energy production and normal carbohydrate metabolism. Co-Q10 has also been proved useful in controlling blood sugar levels.
Word of mouth recommends taking boron, or eating apples, which contain boron, to boost estrogen levels, but I can’t find any scientific research endorsing this is a solid idea.
Agnus castus (Vitex/chastetree berry)
Chasteberry anecdotally helps to stimulate and normalise the function of the pituitary gland, which controls the release of LH and FSH, which signal the menstrual cycle.
Saw Palmetto (Serenoa repens)
Saw palmetto is an herb that is traditionally considered in light of its success in treating prostate problems caused by an imbalance of hormones (including excess testosterone). It is a small palm tree found in North America and the berries of the tree are used in tinctures or capsule form. Research has shown that saw palmetto works as an anti-androgen, which can be very helpful given the high levels of testosterone in PCOS.
Milk Thistle (Silybum marianum)
This is one of the key herbs for the liver. It helps to protect your liver cells against damage and to promote the healing of damaged cells, so improving the general functioning of the liver and all its detoxifying properties.
Spearmint tea also counts. The mechanism is unknown, but spearmint tea has been shown to significantly reduce circulating free testosterone levels in women with hyperandrogenism.
Exercise is an excellent way to increase insulin sensitivity and promote metabolic fitness.
A great deal of healing and hormone production takes place. During the night, when cortisol levels are low, and when the body is recharging, enables the hypothalamus and pituitary glands to send their signals to reproductive tissues uninterrupted.
Optimize thyroid function
If you have hypothyroid, or even subclinical hypothyroid, try addressing this issue before getting on different PCOS medications. Hypo- or subclinical hypo- thyroidism os often the underlying cause of reproductive failure. To understand more about hypothyroid and PCOS, see my recent post on PCOS pathology.
Blood sugar medication: Metformin
Metformin is for many people a wonder drug. Most everyone on the standard American diet I believe could take the drug and see an improvement in metabolism. Metformin prevents the uptake of sugars in the gut, and it improves the efficiency of the insulin response, thereby creating greater insulin sensitivity and reduced testosterone levels. Metformin is great for overweight women with PCOS who also tend to be insulin resistant. Metformin is usually used to treat diabetes.
Metformin has also been shown to decrease testosterone levels even in PCOS patients who don’t test positive for insulin resistance. Metformin may directly impede the production of testosterone in the ovaries. Personally, I am a lean woman who doesn’t test positive for insulin resistance. I took metformin for six days and ovulated for the first time in a year.
Birth control pills
Yaz, Yasmin, and Ortho-try-cyclen are popular choices. But there’s a lot out there on birth control and I will write about the various options and implications of them all as soon as I can. Birth control is effective in “treating” PCOS by increasing either estrogen or progesterone levels, though usually both. However, birth control doesn’t solve the underlying issue. In fact, many women experience even greater dysfunction in their cycles once they go off the pill. As one popular example, some women began taking birth control as teenagers. They continued taking it until they want to have babies, yet once they got off the pill, they found themselves breaking out for the first time in decades and unable to conceive. Birth control pills are great for mitigating PCOS symptoms, but they will never make you more fertile, and they rarely restore hormonal balance.
Women who don’t menstruate are proscribed progesterone medications by their doctors in order to induce menstruation. How it works is that these women take progesterone pills for ten day. A week later, as the progesterone levels fall, estrogen levels rise, and the pituitary and ovaries read this as a signal to shed the corpus luteum.
Because amenorrhea increases the risk for endometrial cancer, amenorrheic women are advised to induce menstruation every few months. Some go years without ill effects, and this depends on each individual’s PCOS pathology and hormone levels. Progesterone also might help jumpstart your system back into more normal health, such that you can take it for a while and then afterwards have achieved enough of a cycle to continue functioning without progesterone. This is a good thing to do if you are trying to balance your hormones via a more natural method, such as eliminating soy from your diet or losing weight.
These are my favorite medications, mostly because they have served as a great crutch while I work on the rest of my issues. Metformin is technically one of these, but other good options are spironolactone and flutamide. Spironolactone is the safer and more efficacious of the two, so almost everyone pursues this option first.
Antiandrogens act to block or inhibit testosterone activity in the body. For this reason, they are often proscribed for acne or hirsutism, helping women cope with these nasty issues while they try to sort out the rest of their endocrine health.
Spirionolactone, in particular, is interesting. It is normally proscribed for high blood pressure, but it is proscribed off label to help women reduce their testosterone levels. Spiro is shaped very similarly to testosterone, so it sits in receptor sites and blocks activity. This is why it’s so effective against acne. Additionally, it helps prevent testosterone production itself by inhibiting 17α-hydroxylase and 17,20-desmolase, which are enzymes in the testosterone biosynthesis pathway.
With Spiro, estrogen levels increase via enhancing the peripheral conversion of testosterone to estradiol and by displacing estradiol from sex hormone-binding globulin (SHBG). Spiro actually decreases serum testosterone and increases serum estrogen levels. I really can’t speak more highly of it. The one great issue is that it creates birth defects, since testosterone is completely blocked, so Spiro absolutely cannot be taken during pregnancy.
Perhaps most importantly, Spiro has an excellent success rate with getting women to ovulate. In this study, 11 out of 13 women began ovulating after a few months of treatment.
Spiro decreases testosterone activity in the body. For this reason, it is an excellent treatment for hyperandrogenic symptoms such as hair loss and hormonal acne.
Ovarian drilling is exactly what it sounds like—in this course of treatment, a woman lays on a table and a doctor inserts a microdrill through her abdomen and into the ovaries, creating tiny holes. These holes puncture the thick endometrium of amenorrheic women and reduce testosterone production. Ovarian drilling to me seems like a great option, but the complications if something goes wrong include permanent infertility. For this reason, many people leave this option as a last resort.
A final relevant point is that OB/GYNs are decent doctors for PCOS, but the best specialist to see is a reproductive endocrinologist. This is my personal area of expertise, but I cannot provide you with the full range of testing that certified reproductive endocrinologists can.
I’ve read a lot about PCOS, but not everything, and this is really a summary of everything, more or less, that I’ve discovered. In any case, my hope is you’ll hop on google and figure out how to tailor my starting points to your own needs. That has been my greatest lesson with PCOS. It’s all about experimentation, your own body, diligence, and patience.
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.
What causes PCOS?
Many of the PCOS “experts” in the world do not understand fully the connection between the endocrine system and the reproductive system. Because of this, they miss a very important link between metabolic syndrome and PCOS. I have read maybe a dozen books about PCOS that recommend nothing but taking birth control pills in response. This puts a patch on a problem that is, in the authors’ views, a simple result of genetics. Some authors go so far as to recommend a low fat, low carbohydrate, moderate protein diet. If a woman tries to eat that way, what is possibly left?
Others—the real doctors, not the one’s publishing books—understand that PCOS is a disorder of the endocrine system. It is not just an ovarian problem, but is rather a problem of hormone signaling to and within the ovaries. This means that ovarian hormone production, pituitary action, and even hypothalamic action are all crucial for proper reproductive health. Check out the Journal of Endocrinology’s 681 articles on PCOS if you want to know more about that.
What makes PCOS so hard for doctors to figure out is not just 1) the grab bag of symptoms but also 2) the heterogeneity of its population. There are two primary groups of PCOS patients. In the first group are about 60 percent of the patients, all of whom are overweight. More importantly, they are insulin resistant. High levels of insulin in these patients shift hormonal balances away from estrogen and towards testosterone. Insulin directly stimulates testosterone production. It’s pretty clear to endocrinologists how to fix this problem. Lose weight, and create better insulin sensitivity. Low carbohydrate (specifically low fructose) diets, exercise, and intermittent fasting are all excellent means by which to do this. The issue is much more complicated than this–really, it is, and many overweight women still have some issues when they lose weight–but it can more or less be boiled down to these steps. On the other hand, the problem is a fair bit more complicated for the other 40 percent, the “thin cysters.” If it’s not overt insulin resistance causing their issue, what is it?
Things that give people PCOS and why
Overweight, metabolic derangement and/or insulin resistance
Like I just mentioned, metabolic derangement is the single greatest cause of reproductive derangement in women. Insulin makes ovaries produce testosterone. This is bad news. We all need testosterone—it’s the crucial hormone for generating sensation in the clitoris!—but too much can entirely derail that.
Dramatic weight loss
Fat cells are major players in endocrine systems. This means that any kind of weight fluctuation can significantly disrupt endocrine function. Primarily, this is an estrogen problem. Estrogen is produced in fat cells. When people gain weight, their estrogen levels increase (obese PCOS patients might have elevated testosterone AND estrogen). When they lose weight, they decrease. Having high androgen levels is the most universal element in diagnosing PCOS, but having appropriate estrogen levels is also crucial for proper reproductive signalling. Moreover, higher levels of estrogen can block harmful effects of androgens and even reduce circulating androgen levels. For these reasons, it may be more important to have proper balance between testosterone and estrogen rather than having good absolute value of either hormone. For example, in my own case, when I was first tested for PCOS, my testosterone was slightly elevated and my estrogen was slightly depressed. These weren’t alarming numbers in either case, but combined they spelled serious issues.
The jury is still out in the world of science, weight loss, and eating disorders on the long term impact of weight loss. Can someone lose weight slowly and maintain reproductive health? Does the speed with which she loses weight matter? If someone loses a significant amount of weight, will her ovaries ever “learn” to make up for the estrogenic load her fat cells used to give her?
From what I can, the answer to each of those questions is “sort of.” I will use a personal example again to demonstrate. I used to weight 137 pounds. In three months I dropped to approximately 105 and today sit fairly solidly at 120 pounds. At 120 pounds, my estrogen levels have increased. They have not reached the same level I experienced at 137 pounds, when my fat cells were pumping out a lot of estrogen, but it is still much more significant than it was at 105. My testosterone has also dropped, at least minimally, and my LH and FSH have remained “normal.” It seems as though it was not the speed of the weight loss, but the simple fact of having a lower body weight that was hurting me so much. I have been experiencing irregular periods and symptoms of low estrogen such as insomnia and hot flashes since I was a young girl, and I have also been amenhorreic at 137 pounds. The issue goes deeper than simple weight loss and weight gain. Achieving 120 pounds has been helpful, but it has not solved everything.
Excessive exercise or low body fat– or even just weight loss in sensitive individuals
This issue is virtually the same as the one above, except the literature on it is more extensive, and it relies less on the actual production of estrogen in fat cells and more on being in starvation mode. When a woman burns calories at a high rate, and when she consumes a low calorie diet (and also if she consumes a lot of fructose) her leptin response is minimal. This means that less satiety is reaching your hypothalamus. The hypothalamus is in charge of telling the rest of the body how nourished it is, and whether or not it should be running on “conserve” mode and shutting down peripheral systems such as reproduction. To do this, it releases Gonadotropin Releasing Hormone, which signals to the Pituitary to release FS and LSH, the hormones that tell the ovaries to produce sex hormones. Without leptin, GRH is impeded, and the entire neuronal cascade is impeded. No proper balance of pituitary hormones is produced.
It is absolutely crucial to convince the body that it is not starving in order to mitigate PCOS. The problem comes with how exactly to do that. There’s no formula. Exercise less, eat more. Eat different foods. Not fruit. Seems as though other carbohydrates — glucose — have the highest of all leptin responses. Put on weight, achieving at least 22 per cent body fat.
Sex hormones are produced in our bodies via two axes: the first is the specifically reproductive axis which includes the pituitary gland and the ovaries, and the second is the adrenal system. If a body has fatigued adrenals in any significant fashion, it’s hormone cascade can be seriously disrupted. Cushing’s disease, an adrenal disorder that causes abnormal cortisol production, often causes PCOS in its patients.
Literature seems to show, interestingly, that cortisol promotes estrogen production. When women present to evolutionary medicine folks (and regular medicine folks) with symptoms of estrogen dominance, such as PMS or abdominal fat, they are advised to reduce stress. High stress often puts women into states of hyper-estrogenism. This has to do with HPA axis dysregulation in general. A woman can have HPA axis hyperactivity, or HPA axis hypoactivity. In either case, reducing stress will serve to restore natural hormone signalling. It may take some time, but it is the only cure.
Metabolic derangement during puberty
Check out the book Ancient Bodies, Modern Lives by Wenda Trevathan for an excellent book on fertility in general. It’s where I first read this theory, that whatever physiological state a girl is in in when she begins menstruating can affect her cycle for the rest of her life. Trevathan proposes that conditions of famine and bounty are determined by this metabolic state, such that deviating from the start-of-puberty norm triggers famine or bounty responses in a woman’s body. For example, many rail thin women in the world, particularly in developing countries, menstruate their entire lives. But when someone who has a BMI of 25 loses 15 pounds, or maybe has less of certain micronutrients in her system, and also has some metabolic derangement from other sources, her hypothalamus might think this is a period of starvation and turn off her reproductive response.
A lot of evidence in the pathogenesis of PCOS, specifically in thin women, points to problems during puberty, childhood, and even the womb (if someone’s mother’s hormones are messed up, hers will be, too.) Menstruation is kicking into gear earlier and earlier in young girls. The middle teen (~14-16 years old) menarche that used to be the norm is now considered “late,” and the average age of menarche in American girls is 11 years old. Evolutionarily, this is quite young. This is partly because young girls are heavier than they used to be. Menstruation starts when a certain estrogen level is reached in the body, and estrogen is not just produced in the ovaries but also in fat cells. The problem therefore is that the ovaries sometimes start out with a handicap, as I touched on above. They are dependent on the fat cells. So any time weight fluctuates, ovaries necessarily have to adjust, and often do so poorly.
Another factor is related: childhood insulin resistance. Having high testosterone levels at a young age primes the body to always act in that fashion. This spells trouble for the entire endocrine system.
I explored the link between hypothyroid and PCOS for a while last year, and I wrote about it here at my other blog. I abandoned my quest when I didn’t see much improvement and may have overdosed on iodine, unknowingly taking upwards of 2000 percent of the daily allowance for a significant amount of time, but I have remained aware of how important the thyroid hormone is for reproductive function.
Thyroid hormone is made in the thyroid gland. First, however, thyroid stimulating hormone, TSH, is produced by the pituitary (after being signaled by the hypothalamus) and sent to the thyroid gland. This instructs it to make T4. T4, though it accounts for 99 percent of the thyroid hormone in the bloodstream, is inactive, and rather just floats around in until the body needs more of it. T4 is converted to T3 in the liver, and the T3 is then used by every cell in the body. In this way, T3 is the hormone of primary interest. But since it is at the end of the chain, things can go wrong at any step in this process. TSH can be underproduced, and either or both of thyroid hormones can go missing. T4 can be underconverted to T3. Someone can be dealing with an inflamed system, menopause, or Hashimoto’s thyroiditis (accounting for approximately 90 percent of hypothyroid cases), and in each case the functioning of every cell in the entire body is impaired. T3 is as crucial for cellular function perhaps as ATP, so you had best have your thyroid health in mind no matter what your presenting condition. This can be bolstered by proper iodine intake, high dose iodine in the form of iodoral, or supplementation with T3 or T4. Whichever step one takes depends on where her endocrinologist sees the problem occurring.
Because every cell is dependent on T3, and because bodies try to optimize its T3 resources, peripheral systems such as reproduction can be shut down in favor of protecting other systems. If the thyroid is malfunctioning, the hypothalamus may reduce signalling to the pituitary gland in order to protect the thyroid system as much as possible. This is analogous to the phenomena of starvation. Another possible point at which hypothyroidism influences PCOS is at the level of cellular functioning. If there isn’t enough thyroid hormone in a cell, it will shut down or become sluggish independently. Reproductive tissues, such as those in the ovaries, might therefore not have enough energy or resources to produce estrogen at the proper rates.
PCOS patients who present with subclinical levels of thyroid hormone begin ovulating once regular thyroid functioning is achieved. One of my favorite articles reports that thyroid hormone replacement therapy achieves a “significant reduction in total as well as free testosterone,” and also states that “ovarian volumes of patients with hypothyroidism were significantly great compared with controls, and their magnitudes diminished significantly during thyroid hormone replacement therapy.”
BPA, environmental toxins, and endocrine disruptors
I mentioned before that thin women with PCOS present with greater gland and endocrine dysfunction than overweight women. What is the root of this malfunction?
One plausible answer is environmental toxins. One of the most concerning ones is environmental toxins. Almost all fruits and vegetables are covered in chemicals that act as phytoestrogens in the body. Over time, specifically when young, these can have a major impact on reproductive physiology. Some foods are worse than others. The way to mitigate this is to eat organic, to peel vegetables, or to wash them with organic soap. A great way to wash vegetables is to soak them in vinegar for several minutes. Vinegar binds with some of these toxins and will help chelate them off of the skin of the vegetables.
A second endocrine disruptor, perhaps the most prevalent one in American lives today, is BPA. BPA is a polymer leached from plastics that disrupts endocrine function in a way not entirely yet understood, but appears to have estrogenic effects.
When rats are exposed to BPA, their male offspring have decreased fertility, and only after exposure to small doses. Of the male rats, one study concludes:
“The BPA exposed males had a suite of reproductive deficiencies that collectively created subfertility in the rats. Some of these included lower sperm counts, poor sperm motility and cellular defects within the testes. Circulating levels of testosterone, estrogen and other reproductive hormones were also significantly lower.
The BPA exposed males were also significantly heavier than unexposed controls.
Mating behavior was also negatively impacted. The BPA-exposed males took longer to copulate with females and a few failed to copulate at all. These observations suggest that the males had lower sexual motivation.
Potentially most concerning, is that the sons and grandsons of the exposed males were also subfertile, indicating that the germ line itself was damaged by the initial exposure to BPA. The mechanism for this transgenerational effect is unclear.”
Female rats are affected just as strongly, if not worse. THEY GET PCOS. Not only do they present with cystic ovaries, but they have increased testosterone and estrogen levels, and also decreased progesterone. Recall that progesterone is THE crucial hormone for menstruation. They also have lowered fertility and higher BMIs than non-exposed rats.
If that doesn’t convince you BPA is bad, note that this result has also been reported in human females. A high correlation has also been shown between mothers with high levels of BPA having children with mood, behavior, and personality disorders.
Moreover, women with PCOS, both lean and overweight women, have 40 percent higher levels of BPA in their blood than those without. Notably, the levels are even more markedly increased in thin women with PCOS. In thin women, PCOS patients had 1.6 times ordinary BPA levels, and in overweight women the ratio was just 1.3. Some researchers speculate that this is because BPA is being stored in fat cells, while other posit that BPA causes brain-related hormone signaling dysfunction, which could explain why thin people end up having PCOS at all. The question of causation rather than just correlation remains, however: does BPA cause increased testosterone levels or do increased testosterone levels inhibits the body’s ability to clear BPA out of its system? The research is inconclusive.
Hard plastics, the polycarbonate plastics such as #7, are worse than soft plastics. Plastics 1, 2, and 4 seem to be BPA free. Heated plastics leach at much higher rates than cold ones (such that buying frozen vegetables is not as scary as one might originally imagine.) However, just because a plastic is free of BPA does not mean it is free of estrogenic activity. All plastics have EA–Estrogenic Activity–just from different chemicals and in different amounts, with not any of them yet measured significantly. Finally, research has shown that BPA gets into bodies in even higher doses from eating out of aluminum cans than out of plastic. Cans are lined with BPA on the inside, so virtually everything eaten out of a can is swimming in BPA. Here’s a list of consumer tips if you’re interested.
Another source of environmental estrogens is body applications. Parabens are phytoestrogens and are one of the most common elements in lotions and soaps. Consume organic here, or check labels, or, even better, stop washing altogether. Also importantly, there is a lot of BPA in receipts. So if you are a cashier, you can ask your boss to let you wear gloves and she had best say okay. Many people actually already do this.
Glands get hormones pupming into the bloodstream, but the liver filters them. I’ll talk more about what one can do with a liver below.
Pituitary or hippocampal tumors
If LH, FSH, TSH, or Gonadotropin Releasing Hormone levels are significantly impaired, and if all other causes have been ruled, this is an indicator that an MRI should be performed.
1) A high insulin diet – that is, one that is full of carbohydrates, particularly refined carbohydrates and fructose-containing carbohydrates — is particularly bad for women with PCOS. It is not clear what the cause of metabolic syndrome is. Chronically high insulin levels may be the cause, but micronutrient deficiencies, inflammation, and leaky gut may also contribute. For this reason, insulin-minimizing foods such as fat and protein should be eaten in sufficient quantities. Inflammatory foods should also be limited. These include, most notably, grains, sugars, and omega 6 vegetable oils.
2) Soy and phytoestrogens. Soy is a phytoestrogen. Phytoestrogens resemble– but are not chemically the same as–estrogen in the body. This leads to confusion in the endocrine system (and, significantly, breast cancer.) Remarkably, soy may play a greater role in endocrine disruption than BPA.
Phytoestrogens can help mitigate some side effects of low estrogen levels such as hot flashes, but they cannot perform the proper signaling functions of true estrogen. This means that exposure to BPA results in a body totally devoid of proper estrogen. When the body detects “estrogen” in its bloodstream, it stops producing it on its own. In this way, phytoestrogen consumption decrease estrogen levels at the time of ingestion. Perhaps more importantly, however, it might also impair the body’s ability to produce estrogen, since the ovaries essentially get out of practice. This is similar to the issue of gaining or losing weight. Soy, like excess weight, is a “crutch” for the ovaries. But it goes beyond that simple role in that it is a malfunctioning crutch, only working in certain circumstances.
One study measured phytoestrogen levels of different foods, and while some vegetables had an order of magnitude greater than others, soy itself has 10,000 units per gram, rather than 4 or 5 hundred like other potent vegetables.
4) Dairy. Pregnant cows produce a protein that inhibits testosterone binding mechanisms, such that dairy is the most androgenic category of foods. This spans butter, milk, yogurt, cream, and any product from a pregnant cow. Moreover, dairy also has a significant insulin response, which can irritate acne and PCOS.
Other foods have less dramatic impacts but may be important to consider for hypersensitive PCOS patients.
5) Factory farmed meat is injected with Bovine Growth Hormone, which can increase insulin-like growth factor 1 in humans. This is bad. Other hormones such as estrogen and testosterone are approved by the FDA for injection into the animals via an earpiece each animal is implanted with at birth. The FDA claims that even with supplementation the animal’s hormonal profile falls within normal ranges, but I’m skeptical. As a personal example, aside from noticing that my acne gets worse whenever I eat meat, chicken, or any other farmed animal (not fish), I also noticed that while in Taiwan I rarely got new cysts, except for one day I ate hamburger meat from Costco.
6) Cruciferous vegetables. These veggies not only act as goitrogens and can decrease thyroid functioning when eaten raw, but they also promote the activity of cytochrome P450 enzyme CYP1A2. This enzyme resides mostly in the liver and is responsible for clearing estrogen out of the system. This is not an issue in regular individuals, and in moderate doses. It is only an issue for seriously dysregulated women who over-consume cruciferous vegetables.
The one food that has been found to reverse this “on” effect on cytochrome P450 enzyme CYP1A2 of cruciferous vegetables in the liver is grapefruit. This is well documented in the medical literature. Grapefruit is the only food that promotes estrogenic activity without acting as a phytoestrogen. But women who eat a lot of grapefruit should be careful: this enzyme also inhibits the processing of a wide variety of drugs.
What can somebody with PCOS eat? The trick is, first, to experiment with one’s own body. The second trick is honestly not to worry about it too much. There are important things that women should always avoid, such as soy, but what’s most important is making sure all the foods are natural and whole.
The extent to which foods influence the production of hormones can be great in a hyper sensitive person, yet phytoestrogens are thousands of times less potent than endogenously produced estrogens. What this means is that foods might serve as a tool to help women achieve better holistic health and hormone balance, but absolute values of certain chemicals in the body from ingesting certain foods might not ever make a difference. There is no reason to become obsessive about micro changes in the diet. PCOS is a bigger problem than that, and what it requires first and foremost is natural foods, proper body weight, and stress reduction.
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.
What is PCOS? Other than “nasty but not the worst thing in the world”?
PCOS stands for Polycystic Ovarian Syndrome. Though it’s hard to define because the symptoms people suffer vary widely, roughly four percent of women still have it worldwide. Up to 15 percent of women in the states. PCOS is the leading cause of infertility in the Western world.
PCOS is a disorder of the endocrine system. It is characterized by the appearance of multiple small cysts on the ovaries, which is almost always accompanied by elevated male sex hormone levels and decreased female sex hormone levels. The male sex hormones, called androgens, are testosterone, the many varieties of testosterone, and DHEA-S. The female sex hormones are all of the varieties of estrogen and progesterone. This imbalance results in a number of problems. These include :
-Oligo- and anovulation
-Irregular or absent menstruation
-Increased risk for metabolic symdrome, diabetes, heart disease, and ovarian and endometrial cancers
-Male pattern hair growth (hirsutism)
-Male pattern hair loss (alopecia)
-Weight gain and increased difficulty in losing weight
In order to understand how menstrual dysfunction occurs, it is important first to review normal menstruation:
The first day of a menstrual cycle is the first day of bleeding. During this period, the lining of the uterus is shed. This bleeding constitutes the first 3-8 days of the first half of the menstrual cycle, which lasts about two weeks and is called the follicular phase. During the follicular phase, levels of estrogen rise and make the lining of the uterus grow and thicken.
Detecting elevated estrogen levels, the pituitary gland increases its production of follicle-stimulating hormone throughout the follicular phase. This hormone stimulates the growth of 3 to 30 follicles. Each follicle contains an egg. With time, the levels of FSH decrease, so only one of the follicles continues to grow. It produces estrogen, and other stimulated follicles break down.
Detecting this shift, the pituitary now releases luteinizing hormone. This makes the follicle bulge and rupture, releasing its egg. This is ovulation. During ovulation, testosterone, that is otherwise constantly produced at low levels by the ovaries, surges, and estrogen drops. Estrogen is required for serotonin production, which is why many women might experience depression during this time.
After ovulation comes the luteal phase. Here the ruptured follicle closes and forms the corpus luteum. This makes the endometrium thicken, which produces progesterone. Estrogen is on the rise again, too, after ovulation. But if the egg is not fertilized within about two weeks, progesterone levels fall, which triggers shedding and bleeding. Here the cycle begins again. Cycles are generally “known” to be 28 days long, but the length of a regular, healthy cycle can vary from ~20 to ~35 days.
Doctors are not sure where the problem enters into the picture with PCOS, but it probably varies. Some options are as follows:
-Low levels of the hormone sex-hormone binding globulin, a “result” of PCOS, decreases the rate of conversion from testosterone to estrogen. This might make estrogen too low to send the proper signals to the pituitary.
-High androgen levels coming right from the ovary or from the adrenal glands can block estrogen and progesterone activity.
-Insufficient pituitary signaling with LH or FSH could be the primary problem. In PCOS, the ratio of LH to FSH is typically around 2:1, instead of the more normal 1:2. This is presumably because the PCOS patient’s pituitary gland wants her to menstruate but she simply is not.
-Finally, the one hormone that is absolutely crucial for menstruation is progesterone. When looking at all of these issues, it is a break in the line towards progesterone production that is the likely cause of disordered menstruation. Without progesterone, the corpus luteum never “knows” when to shed.
In all cases, it’s all very complicated. The question is a tricky one. Therefore, it’s important to test testosterone, DHEA-S (the testosterone precursor, an androgen), estrogen, progesterone, LH and FSH at the very least when trying to figure out an endocrine problem. A liver panel, fasting glucose levels, thyroid tests, micronutrient levels, and adrenal hormone such as cortisol are all important for background endocrine understanding.
Some people in the world of evolutionary medicine posit that PCOS is present in the world today because it was evolutionarily advantageous in a hunter-gatherer environment. This hypothesis falls in line with the “thrifty gene” hypothesis, which states that those humans who are best at conserving energy are the best at reproducing. In this instance, an obese woman, or a woman with PCOS, would be able to always have babies during a famine because she is so good at storing and using fat. The “famine” stage for her makes her fertile. The times of plenty, on the other hand, would make her infertile. This hypothesis might work with overweight PCOS patients, but it doesn’t account for the million PCOS patients who aren’t overweight.
And most importantly, just like with diabetes, solely because PCOS may have provided an advantage in evolutionary times does not mean we do not want to treat it as a medical problem in contemporary society.
In the next post, I’ll cover the apparent causes of and influences on PCOS.