PCOS, a primary cause of infertility, affects 12% of reproductive-age women, mainly in their 20s and 30s; responds well to straightforward changes in diet and activity
Polycystic ovary syndrome (PCOS), also known as Stein–Leventhal syndrome, is a chronic endocrine and metabolic disorder characterised by obesity, head hair loss, excessive body hair, acne, menstrual irregularity, polycystic ovaries, failure of ovulation and infertility.
In this blog, we will explore the symptoms and causes of PCOS, the range of treatments available, and the best ways to beat it. But first, let’s look at a real-life example.
https://inews.co.uk/inews-lifestyle/harnaam-kaur-proud-pcos-2150987
“Losing significant weight, she also got pregnant”
Sarah, a 29-year-old lady, presented with severe hair loss that did not respond to drugs, coupled with excessive body hair, particularly on the chin. She had lost confidence and avoided socialising with friends and using public transport.
She was worried that she had failed to conceive, as she had been married for seven years. She had irregular periods, often missing them for a couple of months. She had mild PMS and a history of breast cysts, which have improved after regularly eating broccoli sprouts.
Her diet was high in sugar and processed carbohydrates. She also snacked on biscuits, crisps and chocolates. She drank ready-made fruit juices and enjoyed a few glasses of wine in the evening.
She reported constant hunger and fluctuating energy levels, with a significant afternoon slump that improved in the evening. She went to bed after midnight and slept 6 hours but did not feel refreshed in the morning.
She had a round body with thick, heavy limbs. Her face had discreet patches of acne. Her BMI of 34.8 (obesity range) and WHR of 0.95 suggest central obesity. Her blood pressure was mildly raised to 135/85.
Her Apple Watch revealed recurrent drops in oxygen levels at night; sleep studies confirmed mild sleep apnoea, which was insufficient to prescribe the mask. Fertility tests revealed high androgen, and an ultrasound scan confirmed PCOS.
She was advised to modify her lifestyle and lose weight.
Sarah walked outdoors and on the treadmill; she lifted weights and practised Pilates. Despite regular physical activity, she could not lose weight. On the contrary, she had recently gained 9kg. She was worried because her father, who was also obese, died suddenly of a heart attack at age 50.
After visiting The Vitality Clinic, Sarah worked hard to adopt a low glycaemic index (LGI) diet, applying severe calorie restriction. She initially went on intermittent fasting and later fasted longer, supported by appropriate supplements.
With this regime, she finally lost significant weight and was pleased to report that she also got pregnant.
The normal cycle and ovulation
A follicle is a tiny, fluid-filled ovary ball containing an egg. Every woman has about half a million of them in puberty. In each menstrual cycle, one follicle grows to produce hormones and, at ovulation, releases an egg around day 14.
Follicle growth occurs under the influence of the gonadotrophins – luteinising hormone (LH) and follicular-stimulating hormone (FSH) from the Pituitary gland in the brain. LH increases androgen synthesis in the ovarian theca cells. FSH converts androgens into oestrogens, stimulating follicle growth and maturation to release an egg ready for fertilisation.
Scans can assess the size and number of follicles during fertility tests. The number of follicles and the quality of eggs decline with age.
Why does PCOS occur?
PCOS occurs in the ovaries with raised androgen. Excess androgen impairs follicular growth and disrupts oestrogen synthesis. Low oestrogen triggers the release of more LH than FSH, resulting in a substantial increase in androgen, the hallmark of PCOS.
Persistently high LH results in hyperplasia of theca cells in the ovaries, with follicle growth being arrested at different stages. Cysts form along the ovary periphery, giving the ovaries a pearl-like appearance typical of PCOS.
High insulin raises LH, the primary cause of excessive androgen production. It also lowers sex hormone binding globulin (SHBG), which binds to androgen, leading to a higher level of free (unbound) active androgen (the male, unhelpful hormone).
PCOS diagnosis comprises three primary signs – high androgen levels, ovarian appearance, with at least one ovary greater than 10ml in volume with ten small cysts, and a failure to ovulate.
Causes of PCOS
High-calorie diets of sugar and processed carbs may cause PCOS. This alters gut flora, resulting in chronic low-grade inflammation and insulin resistance, causing obesity and raising androgen.
Recent studies found a link between PCOS and a decline in gut microbiome diversity, a decrease in beneficial bacteria and an increase in pathogenic ones. These changes increase the permeability of the gut mucosa, which in turn increases the passage of bacterial toxins – lipopolysaccharides (LPS) into the bloodstream. The immune system’s overactivity disrupts insulin receptors, causing insulin resistance and high insulin levels. It also increases androgens in the ovaries and interferes with the follicles’ growth.
Other factors that can contribute to PCOS include lack of vitamin D, chronic stress and smoking.
Smoking causes chronic low-grade inflammation and oxidative stress (rusting) and increases free (unbound) testosterone but decreases oestrogen, resulting in ovulation failure.
Polycyclic aromatic hydrocarbons (PAH) are chemicals produced in Fried, fast, and smoked food. PAH also exists in cigarette smoke and the burning of coal, wood, and garbage. Increased PHA levels in women are positively correlated with an increasing risk of PCOS.
There is also growing evidence that environmental pollutants contribute to the development of PCOS. One study revealed that plastic (BPA) levels were higher in women with PCOS compared with healthy controls. Another study found that increased blood BPA levels were positively associated with serum androgen levels in PCOS women.
PCOS is not a precancerous condition, but high androgen, its direct cause, increases the risk of endometrial cancer and type 2 diabetes.
Treatment
Cornerstones in managing PCOS include adopting a healthy diet, exercising regularly, having restful sleep and reducing stress. These steps are crucial in dealing with obesity, the main component of PCOS. They should lower insulin levels and restore a healthy body weight. Many studies have demonstrated that interventions that lower insulin resistance reduce androgens and improve PCOS.
A low glycaemic index (LGI) food reduces waist circumference, fasting insulin, total cholesterol and triglycerides, and androgen without altering fasting glucose. Adding exercise and omega-3 boosted HDL (the good guy) cholesterol.
High fibre in LGI food feeds the gut flora to release short-chain fatty assets (SCFAs), which restore gut health. LGI diet may alter appetite-regulating hormones. In a study, an LGI diet lowered ghrelin (the hunger hormone) while increasing glucagon in women with PCOS. A meta-analysis concluded that an LGI diet is effective, and dietary assessment should be offered to all PCOS patients.
A ketogenic diet (KD) restricts total carbohydrates in favour of plant-based fat, lowers body weight and blood glucose, and improves the menstrual cycle. It also improves liver function in obese women with fatty liver and PCOS.
In one study, a 12-week ketogenic diet reduced body weight, BMI, glucose, insulin, triglycerides, and cholesterol levels in women with PCOS while increasing HDL levels.
KD may yield even better benefits than an LGI in PCOS patients who have a metabolic syndrome compounded with severe obesity.
Exercise
Increasing physical activity in PCOS patients optimises their metabolism and enhances insulin sensitivity. However, it depends on the intensity of the exercise rather than the duration.
A meta-analysis suggests vigorous exercise may significantly affect body composition, insulin resistance and cardiorespiratory fitness. Therefore, women with PCOS should be advised to engage in vigorous exercise and resistance training.
Microbiome
The link between PCOS and the gut microbiome has stimulated new PCOS treatments, including prebiotics, probiotics and faecal microbiota transplants, with excellent results.
A 12-week probiotic course of beneficial gut bacteria, Lactobacillus acidophilus, significantly reduced the body weight and BMI of PCOS patients. Prebiotics (bacteria food) help to control blood glucose, triglyceride, and total cholesterol while increasing HDL levels.
Faecal Microbiota Transplantations (FMTs) boost short-chain fatty acids (SCFA), especially butyrate. This improves intestinal permeability and stimulates immunoglobulin production, defending the gut lining and restoring health.
Acupuncture also improves metabolic functions in PCOS by modulating neuro-hormonal activities. It increases β-endorphin, which affects the release of gonadotropin to induce ovulation and restore the menstrual cycle.
Studies have identified effective supplements, including vitamin D, resveratrol, alpha lipoic acid, omega-3 and berberine.
Pharmacological treatment
Physicians tend to use oral contraceptives, anti-androgen agents, insulin sensitisers and ovulation inducers in combination.
Oral contraceptives (OCs) are the first-line management protocol for menstrual abnormalities and hirsutism/acne in women with PCOS. Finasteride is another treatment used to manage hirsutism (excess body hair) and other symptoms of high androgen in PCOS patients.
Insulin sensitisers such as metformin can trigger ovulation by reducing insulin resistance, decreasing levels of circulating androgens, and enhancing the menstrual cycle.
Comparing metformin and lifestyle interventions in PCOS-afflicted women, both groups experienced a significant decrease in BMI; however, only the metformin group experienced a decline in testosterone levels.
Another randomised controlled trial evaluating the impact of metformin on body weight in obese PCOS women found that the drug significantly reduced BMI without the need for lifestyle changes and had a positive effect on blood fat.
In fertility treatment, clomiphene citrate is the first-line medication to induce ovulation. It increases FSH to stimulate follicular growth, followed by an LH surge and ovulation. Low-dose gonadotropin therapy can also support follicle maturation and ovulation.
So, my friends, you can see that you can reverse or avoid PCOS through straightforward lifestyle changes, which are far less complicated than pharmaceutical interventions – and come with only positive side effects – which cannot be claimed for their chemically dependent equivalents. Please share your thoughts and questions by commenting on this piece, and please subscribe to the newsletter so you don’t miss further vital information. Thank you!
References
Polycystic Ovary Syndrome: Etiology, Current Management, and Future Therapeutics
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9964744/
Polycystic Ovary Syndrome: A Comprehensive Review of Pathogenesis, Management, and Drug Repurposing
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8775814/
A review on critical appraisal and pathogenesis of polycystic ovarian syndrome
https://www.sciencedirect.com/science/article/pii/S2666396124000062
Polycystic ovary syndrome: pathophysiology and therapeutic opportunities
