Diagnosing PCOS

“50% of women with PCOS go undiagnosed and it takes 5-7 different doctors to eventually get a diagnosis”. This is unacceptable.

Diagnosing PCOS is not that hard to figure out:  periods may be irregular,  there may be acne, excessive facial or body hair, head hair loss, infertility,  there may or may not be cysts on the ovaries on ultrasound, there may be glucose intolerance or a family history of diabetes. Doctors need to look at the whole symptom picture and a) not mask the problem with birth control pills and b) check some hormone blood work.

http://6abc.com/health/symposium-spotlights-polycystic-ovary-syndrome/666773/

PCOS: Are Birth Control Pills and Metformin the Only Treatment?

That depends on who you ask.  If you ask a medical doctor, gynecologist or endocrinologist, the answer will be yes or possibly a drug called spironolactone and Accutane for the acne.  If you ask a naturopathic doctor, the answer will be “not by a long shot!”.  There are numerous natural treatments for PCOS that can not only ease the symptoms, but also address the underlying cause of the condition and build up your body at the same time. Why the disparity in answers?  Because Medical Doctors are not trained in and have little or no knowledge of naturopathic medicine.  If you are looking for an alternative to drugs for PCOS, the best person to ask is not the person who is only trained in the drugs.  It’s like asking your mechanic “what is the best dog food?”  He or she may offer up an opinion on what to feed Rover, but it’s not coming from an expert on the subject. The best person to consult regarding natural remedies or alternatives to drugs for PCOS is a licensed naturopathic doctor who specializes in women’s health and PCOS.

3 Common Misconceptions about PCOS

  1. All women with PCOS are overweight or obese – this is not true, up to 40% of women with PCOS are thin.
  2. Women with PCOS are infertile – possibly if they don’t address the root of the problem, but I’ve helped many women with PCOS conceive and have healthy, natural pregnancies.
  3. All women with PCOS have high testosterone levels.  Nope!  Many do, but others have different reasons why they’re not ovulating regularly such as high prolactin, high DHEAs, high androstenedione etc.

 

Can PCOS Women be Thin?

Absolutely!  If your doctor has told you that you don’t have PCOS because you don’t “look like it”, then he or she is wrong.  You cannot diagnose PCOS or rule it out based on what someone looks like.  You can have a suspicion that a woman has PCOS if she’s overweight, has acne, thinning head hair and excess facial hair, but even then there are other conditions that need to be investigated such as adrenal hyperplasia. Up to 40% of PCOS women are thin.  Does that mean that these women aren’t insulin resistant?  Not necessarily, even thin women with PCOS can be insulin resistant.  Confusing isn’t it?  Sometimes, partly because everyone is different and PCOS can manifest many different ways and have several different root causes.  This is why it’s best to consult with someone who is well versed in PCOS, not all family doctors or even endocrinologists are.

Signs and Symptoms of Hormone Imbalance

How would you know if you had a hormone imbalance? Most of the women I see already have an inkling that something is out of balance by the symptoms that they are experiencing:

  • Hair loss
  • Acne
  • Irregular periods
  • Night sweats
  • Hot flashes
  • Infertility
  • Heavy periods
  • Painful periods
  • Fibroids
  • Ovarian cysts
  • Uterine polyps
  • Excessive facial or body hair
  • PMS
  • Premenstrual migraines

Most often they have already visited their family doctor who “checked their hormones” and told them “everything is normal” or offered them the birth control pill.

There are three main problems here:

  1. By checked their hormones, most doctors mean they’ve done a very superficial screening of hormones, LH, FSH, maybe estradiol and maybe progesterone, but often not measured on specific dates of the menstrual cycle that make the results clinically meaningful.
  2. When “everything is normal” even though you feel that hormones are imbalanced, it’s because the “normal” ranges for hormones are extremely wide and so even abnormal people fall into the “normal” range.
  3. Birth control pills only mask the existing hormone imbalance, they don’t correct it.

If you feel like you have a hormone imbalance, always ask for a copy of blood work results so that you can see exactly how extensive testing was and exactly where your results fall in the “normal” range (normal is always in quotes because lab ranges rarely refer to what is actually normal, it is more often an average of unhealthy people).  99% of the time you will find that either: a) only a very few hormones have been tested and/or b) one or more of your results were borderline.

What Kind of Carbs Should I Eat?

The best kind of carbs are the ones that have minimal impact on blood sugar levels. High glycemic index and high glycemic load carbs (for example rice, wheat and wheat products) cause a sharp spike in blood sugar levels and insulin. A glycemic index of less than 55 is considered low and glycemic load of less than 10 is low. Rice, even if it’s brown rice, has a glycemic index of 58-84 and a glycemic load of 19-46. This will mean high insulin requirements to deal with the resulting spike in blood sugar.

So what’s wrong with that? Insulin’s job is to transport all of that sugar from the blood into the muscle, fat and other tissues and it causes the liver to store glucose as it’s storage form, glycogen. Once there is enough stored glycogen, the liver starts to produce fatty acids, which can be turned into triglycerides in fat cells, contributing to high blood lipids, atherosclerosis and fatty liver disease.

Insulin also preserves body fat, the more insulin the less breakdown of fat tissue. Not so good if you are trying to lose weight.

Insulin can also lower blood levels of potassium, a vital mineral for normal heart function.

Frequent insulin production, induced by frequent carb intake, can lead to insulin resistance or pre-diabetes. Insulin resistance can cause infertility, PCOS, heart disease, and is linked to an increased risk of cancer as both insulin and IGF1 have a role in tumor initiation and progression in insulin-resistant patients.1. How would you know if you were insulin resistant? Neither you nor your doctor would likely know until the point that your fasting blood sugar became abnormal, at which point you are diabetic. If you have PCOS you are already at a much higher risk of being insulin resistant and eventually becoming diabetic.

So what are the best kinds of carbs? Whole grain (not processed into bread, crackers, cereal, pasta), high fiber and lower glycemic index grains like quinoa, amaranth, lentils, beans and to a lesser extent spelt and kamut. Should you eat these at every meal? Probably not, best to give your body a break from the need to make insulin at every meal, even if it is a lower amount. Aim for small servings of lower glycemic index and load grains, once per day.

Have I Ever Put Anyone on a Zero Carb Diet?
No, because that is ridiculous. Unless you consumed nothing but water, you would have to be taking in carbs, even meat contains some amount of carbohydrate. For the average sedentary person, vegetables and fruit will supply sufficient carbohydrate for what your body needs. More active than usual? Great, add in a serving of one of the lower GI/GL carb sources listed above.

As a naturopathic doctor, it is my obligation to “do no harm”. If you suffer from a condition where frequent insulin production would do harm, like PCOS(2-6), I am bound by the Hippocratic oath to recommend decreasing carb intake and the need to make insulin. I’m happy to provide counselling and assistance in making the transition from a higher carbohydrate diet to a lower carbohydrate one.

1. Source: Exp Diabetes Res. 2012; 2012: 789174. Insulin Resistance and Cancer Risk: An Overview of the Pathogenetic Mechanisms, Biagio Arcidiacono, Stefania Iiritano, Aurora Nocera, Katiuscia Possidente, Maria T. Nevolo, Valeria Ventura, Daniela Foti, Eusebio Chiefari, and Antonio Brunetti.
2. Low carb ketogenic diet improves weight, percent free testosterone, LH/FSH ratio & fasting insulin in women with obesity & PCOS over a 24 week period. (Mavropoulos et al, Int J Endocrinol Metab. 2012)
3. PCOS patients ingesting a high protein diet experienced greater weight loss & body fat loss than the standard protein diet. (Sorenson et al, Am J Clin Nutr, 2012 )
4. In women with PCOS, consumption of a diet lower in CHO resulted in preferential loss of fat mass from metabolically harmful adipose depots, whereas a diet higher in CHO appeared to promote repartitioning of lean mass to fat mass. (Gossa et al, Metabolism, Oct 2014)
5. Energy restriction & weight loss in PCOS improve ovulation rates, conception, hyperandrogenemia, glucose & insulin levels, insulin resistance & satiety hormones. A low carb diet has an additional effect to caloric restriction in terms of weight loss. (Frary et al, Minerva Endocrinol, June 2014)
6. A diet containing 25% carbohydrates improved insulin resistance, whereas a diet that included 45% carbohydrates did not. Source: International Journal of Obesity and Related metabolic Disorders 20 no. 12:1067-1072

IBS and PCOS

What do these two things have in common besides being acronyms for common medical syndromes (Irritable Bowel Syndrome and Polycystic Ovarian Syndrome)? Recent research suggests that there is a connection between insulin resistance and leaky gut, which may then in turn cause irritable bowel syndrome. Want your gut to be healthier? Cut back on carbs and exercise daily to maintain normal insulin levels. Your hormones will be better balanced and you’ll be less prone to food sensitivities.

Polycystic Ovarian Syndrome or Not?

Irregular periods, acne, hair loss, fatigue, weight gain, sluggish metabolism, at first glance these symptoms seem to point to PCOS. However, blood tests show a different story, in PCOS you would expect to see high androgen levels (testosterone, DHEAs) but this patient has low testosterone, low DHEAs, low estradiol and here’s the kicker – high cortisol! Her doctor had refused to do the cortisol testing which ultimately provided the solution to the puzzle of her symptoms which she has complained to her doctor about for years. It still remains to investigate why her cortisol is elevated. There are herbs that can be used to lower cortisol, but we’ll refrain from that until we can collect more data on why it’s elevated.

It’s easy in medicine to make assumptions and jump to conclusions, but this patient is a perfect example of why doing our due diligence and thoroughly investigating through diagnostic testing is important.

Polycystic Ovarian Syndrome Theories

Some of the prevailing theories as to what is going on with women with PCOS include:

1.  A defect in insulin action and secretion that leads to higher blood insulin levels and insulin resistance.
2.  A defect in the nervous and endocrine systems leading to an exaggerated LH (luteinizing hormone) pulse frequency and amplitude
3.  A defect of androgen (male hormone) production that results in enhanced ovarian testosterone, DHEAs and/or androstenedione production
4. An alteration in cortisol metabolism resulting in enhanced adrenal androgen production (Tasoula et al, Clin Endocrinol, 2004)
5. Intrinsic theca (ovarian) cell hypersensitivity to LH stimulation that results from defective inhibition by FSH that may involve inhibin-B signalling. (Hirshfeld-Cytron et al, J Clin Endocrinol Metab, 2009)

In any case, improvement is usually seen through measures that lower insulin such as low glycemic index, low glycemic load diet, stress reduction and daily exercise. Additional support from insulin sensitizing agents like inositol, NAC, zinc, and cinnamon is also helpful.