What causes PCOS?
1. Insulin resistance effect on PCOS
The main driver of PCOS is insulin resistance. Insulin resistance (IR) is when our cells can’t respond appropriately to insulin (a hormone that regulates blood sugar levels) resulting in abnormally high insulin and blood sugar levels. Elevated IR can trigger the production of androgens (male sex hormones such as testosterone), reduce sex hormone-binding globulin (SHBG) and lead to complications such as type 2 diabetes. IR also affects the balance of follicular stimulating hormone (FSH), luteinising hormone (LH), estrogen and progesterone- all of which are important for ovulation to occur. Hence, anovulation (periods without ovulation) and oligomenorrhea (irregular periods) are common symptoms of PCOS (more on this later).
2. Genetics and PCOS
Certain population groups are more likely to develop PCOS and this includes women of Australian Indigenous women, Asian, North African and Caucasian European descent. Women are 50% more likely to develop PCOS if their immediate family has it (such as their mother, sister or aunt). Women may also inherit the ‘gene’ for PCOS from their family members.
3. Exposure to endocrine-disrupting chemicals (EDCs)
Endocrine-disrupting chemicals are substances found in the environment and common ones include parabens, dioxins, bisphenol-A (BPA) and phthalates. These chemicals are found in our foods, personal care products, beauty products and perfumes. They can act as hormone-disrupting obesogens which can contribute to insulin resistance and weight gain. Studies have found women with PCOS have high concentrations of EDCs in their follicular fluid and blood compared to women without PCOS.
Exposure to these prenatally (in the womb) or infancy increases a woman’s likelihood to develop PCOS. EDCs can be passed down trans-generationally for up to 3 generations meaning if someone’s grandmother was exposed to EDC’s then their female grandchildren are at greater risk for developing PCOS.
4. Being overweight or obese and PCOS
Although PCOS can develop in women with any BMI, obesity is positively associated with insulin resistance and is a significant contributing factor in the pathogenesis of PCOS. However, metabolic abnormalities caused by PCOS can also predispose individuals to weight gain. Scientists are still unsure whether PCOS causes obesity or vice versa (similar to the chicken or egg situation).
5. Poor gut health and PCOS
Poor gut health can contribute to hormonal imbalance and poor metabolism. Women with PCOS have a less diverse gut microbiota and altered bacterial diversity. Clinical studies have found certain species such as Catenibacterium, Kandleria, Porphyromonas, Blautia species to be lower and Bifidobacterium and Blautia species to be more abundant in women with PCOS.
Also, one animal study found mice who given faecal transplants from women with PCOS exhibited higher IR, testosterone, luteinising hormones and ovarian follicles compared to the control mice. This indicates the possible involvement of the gut microbiota in the development of PCOS.
6. Inflammation and PCOS
Whilst many of us will be familiar with the acute inflammation that occurs in response to an injury (e.g., a cut) or infection (such as a bacterial or viral infection), inflammation can also occur chronically and in response to stress, long term exposure to pollutants or obesity.
Women with PCOS are more likely to have elevated levels of inflammatory markers (such as C-reactive protein and tumour necrosis factor-alpha). Also, studies have shown chronic, low-grade inflammation increases insulin resistance and consequently excess testosterone production.
Signs & symptoms of PCOS
Individuals with PCOS may present with all, some or none of the symptoms described below which can make diagnosing for PCOS difficult. It’s estimated that up to 70% of women with this condition remain undiagnosed. Individuals may present with symptoms such as alopecia (male pattern balding), acne, hirsutism (excessive body hair), skin tags, dark patches on the skin, difficulty losing weight, and periods that are irregular or absent.
Also, women with PCOS are at increased risk for infertility, mood disorders (such as anxiety, depression) and metabolic disorders such as obesity, diabetes, hypertension and dyslipidaemia. Whilst researchers still aren’t clear how PCOS manifests in mood disorders, there are a few theories as to why. Symptoms of PCOS including excessive body hair, acne and difficulty in losing weight can have devastating effects on one’s self-esteem and quality of life.
Please know, however, whilst the physical and physiological challenges of PCOS may feel difficult- there is support out there and both your PCOS symptoms and moods can be managed through dietary changes, lifestyle shifts, supplements and medication (more on this below!)
How to test for PCOS
Under the Rotterdam criteria, women with PCOS must have two of the following symptoms:
1. Clinical or biochemical signs of hyperandrogenism (elevated male sex hormones)
Hyperandrogenism is most accurately measured through testing the free testosterone rather than total testosterone. However, free testosterone levels can be affected by contraception such as the oral contraceptive pill (OCP), contraceptive patch or vaginal ring as these increases levels of sex hormone-binding globulin (SHBG). SHBG decreases circulating levels of free (active) testosterone. Thus, an individual’s contraception method must be taken into consideration when testing for hyperandrogenism.
Signs of hyperandrogenism include alopecia, acne and hirsutism. But hirsutism may be difficult to observe as women may remove their excessive body hair using the laser hair removal, waxing, shaving, etc and acne may be concealed using make-up.
2. Oligoovulation or anovulation (irregular periods or the absence of ovulation)
An irregular menstrual cycle refers to menstrual cycles that are chronically over 35 days or under 21 days. Our menstrual cycles can become irregular for multiple reasons including psychological stress, travelling, changing contraception, some medications, excessive exercise, under or over-eating. Health care practitioners (HCPs) must consider these factors in their diagnosis of PCOS. It’s also common for adolescent individuals to experience irregular periods for the first 3-6 years of getting their periods thus PCOS is often over-diagnosed in younger women and under-diagnosed in older women.
Additionally, women with PCOS may experience anovulatory regular cycles (periods that occur without ovulation). A blood test during the luteal phase (the week leading up to your period) can help measure the hormones to determine whether a woman is ovulating. Anovulatory periods is a common cause of infertility as women must ovulate to fall pregnant.
3. Polycystic ovaries on ultrasound
Polycystic ovaries refer to when there are at least 25 follicles observed on the ovaries. A transvaginal ultrasound is the most accurate diagnostic tool to assess ovarian morphology. In PCOS these immature follicles are abnormally large and line up on the ovaries to form what looks like a ‘pearl necklace’. It is also important to note up to 70% of young women have polycystic ovaries and hence this test alone is not a reliable test to diagnose PCOS.
4. Additional Tests
Additional investigative tests for PCOS include blood test for sex hormone-binding globulin (SHBG), anti-Mullerian hormone (AMH), DHEAS and androstenedione and female sex hormones (including estrogen, luteinising hormone (LH) and follicle-stimulating hormone (FSH)). Often bloodwork will indicate SHBG, AMH, LH, estrogen, DHEAS and androstenedione to be elevated whilst FSH will be low in women with PCOS.
As women with PCOS are at greater risk for developing metabolic diseases, an HCP may also test for an individual’s triglycerides, HDL cholesterol, LDL cholesterol, blood pressure and glucose levels. These tests help determine the risk for developing cardiovascular disease, diabetes and other metabolic disorders.
Treatment Options for PCOS- natural and conventional
Conventional treatment for PCOS
Symptoms of PCOS manifest differently between individuals and the conventional treatment will treat the symptoms that are specific to the patient. The conventional treatment for PCOS may address acne, hyperandrogenism, irregular menstrual cycles, insulin resistance and/or mood disorders.
1. The combined oral contraceptive pill (COCP) and PCOS
The COCP is often the first-line treatment for PCOS symptoms such as irregular periods and hyperandrogenism. The pill works by reducing the excessive production of androgens by the ovaries and increasing SHBG which further reduces free (active) testosterone levels.
However, some birth control pills can worsen insulin resistance and an individual’s lipid profile and thus may not be the best choice for women who have diabetes and/or high cholesterol. A lower dose of hormones (20 mcg) is preferred for insulin resistance. The pill is also contraindicated in individuals who are over the age of 35 or over, smoke or have hypertension.
It’s important to understand that the hormonal contraceptive pill is not a “fix” for PCOS, it merely masks the symptoms and suppresses the communication between the brain and your ovaries which stops ovulation. It is very common for women to be diagnosed with PCOS after coming off the pill – if this is you, think about what your periods were like before going on the pill? If they used to be regular & you don’t have insulin resistance but you’re experiencing a surge in androgens, androgen-excess symptoms like acne and a delay in re-establishing regular ovulation and periods – this could be temporary post pill PCOS. It’s your body going through a drug-withdrawal process and it can be reversed within 1-2 years with the right nutritional, lifestyle and supplement support aimed at helping reduce androgens and re-establishing ovulation.
2. Insulin lowering drugs (metformin) and PCOS
Insulin lowering drugs lowers blood glucose levels to slow the progression of PCOS to type 2 diabetes. They work by increasing the insulin sensitivity of peripheral tissue, increase hepatic glucose uptake and reduces hepatic gluconeogenesis (glucose production by the liver). Additionally, insulin lowering drugs may also reduce testosterone, reduce LH and increase SHBG (which are often imbalanced in PCOS) which helps to manage PCOS symptoms. However, women may experience unpleasant side effects such as nausea, bloating, nutrient depletion, appetite loss, flatulence and diarrhoea.
3. Anti-androgen monotherapy and PCOS
Anti-androgenic monotherapies are drugs that reduce androgen (male sex hormone) levels to improve hyperandrogenic symptoms such as alopecia, hirsutism and acne. They work by preventing androgens binding to androgen receptors and reducing androgen production. However, these medications are contraindicated in individuals who are seeking to become pregnant as anti-androgen medications can harm unborn children. Therefore, women who are looking to become pregnant in the current or near future should not take these drugs.
Natural Treatments for PCOS
The holistic and natural management of PCOS involves treating the underlying root cause of PCOS, its drivers and mitigating its symptoms.
1. PCOS and physical activity
Physical activity can improve symptoms of PCOS and improve long term outcomes by increasing confidence, improving insulin resistance and assisting with weight management. I recommend choosing the type of exercise that you enjoy as you’re more likely to stick to it. Health professionals recommend 150 minutes of moderate to high-intensity exercise a week, you can choose to break this up to 5 30-minute sessions per week or 3 50-minute sessions weekly.
Cardiovascular exercise has shown to protect against metabolic disorders, improve cardiovascular markers (such as waist to hip ratio, homocysteine levels) and enhance mood. Try downloading the “Nike Run Club app“, google fun dance workouts on Youtube, or listen to a podcast and go for an enjoyable walk in the sunshine. Resistance exercise such as lifting weights helps to build muscle, improve insulin resistance and support a healthy metabolism.
It’s also important to have a couple of rest days or restorative sessions weekly to reduce stress and inflammation levels. Try “yoga with Adrienne” or doing some stretching at home to ensure you are resting adequately in between your workouts.
2. Reduce exposure to endocrine-disrupting chemicals (EDCs)
As previously mentioned, early EDC exposure increases an individual’s likelihood to develop PCOS. EDC’s exacerbate hormonal imbalance and are obesogenic, meaning that they promote fat storage and increase weight gain. We can reduce our exposure to EDCs in the kitchen by consuming organic foods, storing foods in glass containers, use “beeswax wrapping” to wrap foods and never microwaving our food in plastic containers.
We can reduce our EDC exposure in our beauty and personal products by switching to ‘clean beauty’ brands and non-toxic products. Don’t know where to start switching to clean beauty products? Try out our “Acne Moonbox starter kit” which contains our non-toxic, natural skincare essentials. This kit is the perfect starter pack to help you switch over to natural, high-quality skincare and beauty products that won’t mess with your hormones!
3. Manage stress
Stress is our body’s physiological reaction to a real or perceived threat (‘stressor’) and being in a stressed state means we’re in ‘fight or flight mode’. whilst stress protected us against wild animals and other threats back in our caveman days, our bodies don’t know the difference between a wild tiger, a difficult boss at work or overbearing family members- meaning we’re constantly overwhelmed by stress.
Stress is a huge trigger for worsening PCOS and its symptoms. Psychological stress increases blood glucose and insulin levels to result in increased insulin resistance.
To reduce stress, I recommend creating a ‘relaxation list’ and jotting down activities that bring you joy and help to release stress. This can look different for everyone but some of my favourite ways are to take a long hot shower, have a social media-free day, read a fiction book, book yourself a massage (or get a friend or partner to help you out!), journal, stretch and sip on some matcha tea mindfully.
Matcha is an antioxidant-rich, green tea made into a fine powder and is widely enjoyed as a beverage. Matcha contains theanine, an amino acid, which reduces psychological and physiological stress and has shown to reduce anxiety in animal models. It’s believed that matcha activates neurotransmitter receptors (dopamine and serotonin) which have mood-boosting and anxiety alleviating effects. Green tea has also shown to improve insulin resistance, fasting insulin and free testosterone levels, making it the perfect beverage of choice for women with PCOS. You can find our high quality, organic “Luna’s Matcha” product on our website.
4. Prioritise sleep
Sleep disturbances are twice are likely in PCOS, and women with this condition have reported difficulty in falling asleep and staying asleep. The research is still unclear why but metabolic factors such as elevated androgens and insulin resistance are likely to play a role. The potential mental health impact of PCOS may also play a role as increased depression and/or anxiety has a positive correlation with sleep disturbances.
Inadequate sleep quality and quantity can increase fasting blood sugar levels, reduce insulin sensitivity and elevate cortisol levels. Hence, prioritising sleep is essential to manage PCOS.
Magnesium, an essential nutrient, plays a key role in calming the nervous system and promoting restful sleep. It does this by regulating the neurotransmitters (“brain chemicals”) that are involved in the activation of the ‘rest and digest system’ and induction of sleep.
Whilst you can find magnesium in many forms (tablets, powder, spray), we recommend transdermal (‘through the skin’) magnesium. Our “Moon Boost” product is a magnesium spray that’s directly absorbed through the skin for optimal absorption. We recommend spraying it any time of day but especially 45 minutes before bedtime to improve sleep.
5. Eat a low glycaemic index (GI) diet
Managing insulin resistance is a key dietary goal in the management of PCOS and ensuring our blood glucose levels are kept low and stable is essential. When our blood sugars spike, this increases insulin-like growth factor-1 (IGF-1) levels which increases testosterone production.
Limit high sugar foods which worsen IR such as pastries, fruit juices, sodas, ice-cream, white bread and cereals. Instead have a low GI diet and eat whole food carbohydrates such as sweet potatoes, lentils and brown rice which are slow-digesting carbohydrates meaning they won’t spike your blood sugar (glucose) up and down. Also, ensure your meal is balanced with fats and protein to reduce the glycaemic index of your meal, you can do this easily by adding in a tablespoon or two of “Earth Seeds” into your meal- our blend of healthy seeds.
6. Pack in the antioxidants
A 2015 study published by the North American Journal of Medical Sciences study found an anti-inflammatory, Mediterranean based diet which was high in fruits, vegetables, legumes, fish, spices and green tea to reduce inflammation in women with PCOS. This was measured by decreased inflammatory markers such as CRP. Other benefits of this diet included reduced cholesterol, triglycerides, blood pressure, waist circumference and weight loss.
Increase your consumption of good fats, dark green leafy veg, low sugar fruits (such as berries, stone fruit) and anti-inflammatory spices (such as turmeric, cinnamon, ginger). Try out our “Luna’s Gold” which is our anti-inflammatory go-to brew that contains turmeric, ginger and cinnamon.
7. Support the liver
The liver is a key organ that plays a role in insulin resistance. Impaired liver function can result in high blood sugar levels and inflammation. The liver plays a key role in balancing our hormones and blood sugar levels. Women with PCOS are also twice as likely to develop the non-alcoholic fatty liver disease (NAFLD). Our “Half Moon Tea” contains some liver-protective herbs and cleanses the liver to excrete hormonal build up. You’re also getting the bonus of adding extra fluid into your day by drinking this tea and hydration is incredibly important for optimal liver health.
“Healthy hormones, happier periods Ebook” is our in-depth guide which covers the key dietary, lifestyle, gut, liver and environmental factors that contribute to healthy hormones. As PCOS is inherently a condition driven by hormonal imbalance, this eBook is the perfect education tool to optimise your hormones.
- Beeswax wrapping
- Glass storage containers
- NIKE run app
- Yoga with Adriene
- Clean beauty products
- Acne Moonbox Starter kit
- Luna’s Matcha
- Moon Boost
- Earth Seeds
- Luna’s Gold
- Half Moon Tea
- Hormone Reset eBook Bundle
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