Polycystic
ovary syndrome is a hormonal disorder that affects women of reproductive age.
It is characterized by irregular menstrual periods, excess male hormones,
and/or ovarian cysts.
Women
have two ovaries with two crucial reproductive jobs. Our ovaries release eggs
during our menstrual cycle and they also produce three major hormones—estrogen,
progesterone, and testosterone—as well as a few other hormones, like inhibin
and relaxin. The “female” hormones estrogen and progesterone are necessary for
the menstrual cycle. The “male” androgen hormones, like testosterone, are also
needed at low levels in women, although the reasons why are not entirely clear.
One theory is that testosterone is related to female sexual desire and
lubrication (Davis & Wahlin-Jacobsen, 2015). Women with PCOS often have
higher than normal levels of testosterone and low levels of estrogen, creating
a hormone imbalance that interferes with ovulation and can manifest as ovarian
cysts (Housman & Reynolds, 2014).
Ovarian
cysts are very common. They’re typically small, unnoticeable fluid-filled sacs
that don’t cause problems; many of us have had or will have one in our
lifetime, usually without knowing it. Cysts become an issue if they grow to be
large and painful or if multiple cysts grow on the outer edge of the ovaries,
as is often the case in PCOS. It’s also possible for women to have ovarian
cysts due to other conditions, such as endometriosis. But what distinguishes
PCOS from other conditions is the hormonal imbalance. Another technicality is
that women with PCOS actually have ovarian follicles, not ovarian cysts. Which
means: Follicles and cysts look exactly the same on ultrasound, and while the
names are used interchangeably, follicles contain an immature egg, but cysts do
not. Since women with PCOS have trouble releasing an egg each month due to
hormone imbalances, these follicles tend to build up on the ovary over time.
This is sometimes described as looking like a “string of pearls” on the
ultrasound (Housman & Reynolds, 2014).
The
exact cause of PCOS is not known. It runs in families, so it is likely caused
by a combination of genetics and environmental factors. One factor that has
been heavily researched is insulin resistance.
Women
with PCOS have a high prevalence of insulin resistance, regardless of their
weight. They also have a higher risk for other diseases, such as diabetes and
cardiovascular problems, especially if they are overweight (Bil et al., 2016;
Jeanes & Reeves, 2017).
The
risk of type 2 diabetes may be up to four times greater and diagnosed an
average of four years earlier among women with PCOS compared to other women
(Rubin, Glintborg, Nybo, Abrahamsen, & Andersen, 2017). In addition, women
with PCOS are more likely to be obese, with one meta-analysis estimating the
risk of obesity is almost three times higher among women with PCOS (Lim,
Davies, Norman, & Moran, 2012). The weight gain with PCOS can be stubborn
due to the underlying hormonal issues. Insulin resistance and diabetes are huge
risk factors for heart disease if not properly managed.
For
women with PCOS, figuring out how to balance insulin levels through lifestyle
changes is incredibly important for managing PCOS symptoms and for preventing
potentially more serious issues down the road.
A large
Swedish study of 4 million women looked at cancer risk among those who were
diagnosed with PCOS. These women had significant risk for cancer of the
pancreas, kidneys, endocrine glands, endometrium, ovaries, skeletal system, and
blood. More specifically, the researchers found that this cancer risk was
higher across the board among premenopausal women (Yin, Falconer, Yin, Xu,
& Ye, 2018). A leading scientific theory is that increased insulin, blood
sugar, and inflammation contribute to cancer initiation and progression (Orgel
& Mittelman, 2013). Thus, it’s recommended that women with PCOS routinely
screen for cancer while working to normalize their blood sugar, insulin levels,
and weight to reduce risk factors.
There’s
not a single test to identify PCOS, which can make diagnosis difficult and
sometimes confusing, even for doctors. Women with PCOS are often left out of
the medical narrative and can be overlooked or diagnosed with other, more
commonly researched diseases. One study of women in Australia showed that
almost 70 percent of the women who had PCOS had not been previously diagnosed
before the study (March et al., 2010). While there has been debate over the
most clinically relevant criteria for PCOS diagnosis, the Rotterdam Criteria
(Goodman et al., 2015) is the most widely recognized by doctors and researchers.
Doctors
may order blood tests to determine your hormone levels in addition to an
ultrasound or a pelvic exam. Testing for free testosterone is essential for the
diagnosis, while progesterone and anti-Müllerian hormone levels can also be
helpful. Physicians will want to rule out other conditions, especially among
younger women, as irregular periods and acne may just be a normal part of puberty.
Early diagnosis of PCOS is key for normalizing menstrual cycles and protecting
against related risks, such as infertility, diabetes, and cardiovascular
disorders. Women should create a plan with their doctors to address individual
needs, depending on factors such as weight and whether they plan to have
children. Endocrinologists (hormone experts), particularly reproductive
endocrinologists, and ob-gyns are the specialists who are best qualified to
advise on the specifics and tailor a treatment plan to your hormonal needs.
Simple
lifestyle changes—healthy diet and exercise—can assist with weight loss, PCOS
symptoms, and fertility, while also working to reduce risk of other diseases in
the long term, such as type 2 diabetes and heart disease.
Weight
loss is often the first line of defense. If you are overweight, losing as
little as 5 percent of your weight can improve metabolic and reproductive
abnormalities as well as risk for other long-term issues (Stamets et al.,
2004). Numerous studies have shown that lifestyle modifications (exercise and
diet changes) are effective at improving insulin resistance, hormone levels,
and weight loss in women with PCOS (Haqq, McFarlane, Dieberg, & Smart,
2014; Moran, Hutchison, Norman, & Teede, 2011). Other studies have shown
that lifestyle changes in combination with medications are more effective than
medications alone (Legro et al., 2015; Naderpoor et al., 2015).
There
has not been a general consensus on the best diet for women with PCOS. Most
studies base their recommendations on diets for individuals with type 2
diabetes. Good results have been shown for diets that are low-carb, low-GI, and
high-fiber, but more large-scale research is needed.
Foods
containing carbohydrates can be defined by their glycemic index (GI), which is
a measure of how quickly they raise the sugar (glucose) level of the blood.
High-glycemic diets have been shown to be associated with both PCOS and obesity
(Eslamian, Baghestani, Eghtesad, & Hekmatdoost, 2017; Graff, Mário, Alves,
& Spritzer, 2013). On the other hand, several studies have shown that
low-carb and low-GI diets can decrease insulin levels and improve insulin
sensitivity in women with PCOS (Barr, Reeves, Sharp, & Jeanes, 2013;
Berrino et al., 2001; Douglas et al., 2006; Marsh, Steinbeck, Atkinson, Petocz,
& Brand-Miller, 2010).
Picking
carbs that have a low GI, such as vegetables, whole grains, and legumes, can
reduce your blood sugar spike after a meal and can reduce insulin resistance
(Brand-Miller, Hayne, Petocz, & Colagiuri, 2003). Studies have also found
that low-carb diets can help with weight loss in women with PCOS (Berrino et
al., 2001; Goss et al., 2014; Marsh et al., 2010). They also may be able to
help with menstrual regularity, although more research is needed (Marsh et al.,
2010). One thing to keep in mind: Low-carb is different from a ketogenic diet,
which is low-carb and high-fat (more on dietary fats and PCOS below).
High-fiber
diets may be beneficial. While fiber is molecularly a carbohydrate, it is
unlike other carbohydrates in that it does not get digested as it passes down
your digestive tract and therefore does not affect your blood sugar levels in
the same way that other carbs do. Foods that contain a lot of fiber have a low
GI. Diets high in fiber have been shown to help overweight individuals with a
high risk of type 2 diabetes lose weight. Furthermore, research has shown an
association between low-fiber diets and PCOS (Eslamian et al., 2017).
There
hasn’t been much research assessing high fiber diets for women with PCOS, but
one study found that women with PCOS who reported eating more fiber showed less
insulin resistance and had less total body fat (Cunha, Ribeiro, Silva,
Rosa-e-Silva, & De-Souza, 2018). Another study showed that high fiber and
low trans-fatty acid intake were associated with metabolic improvements among
overweight women with PCOS (Nybacka, Hellström, & Hirschberg, 2017). ). And
a third, more recent study found published in 2019 found that lower
testosterone levels were associated with increased fiber intake among women
with PCOS (Barrea et al., 2019). Overall, high-fiber diets seem promising for
PCOS, but more research is needed.
The
Dietary Approaches to Stop Hypertension diet, aka the DASH diet, has been shown
to be helpful for weight loss as well as for reducing insulin and androgen
levels in women with PCOS. It consists of low-GI, high-fiber, and low-calorie
meals rich in fruits, vegetables, whole grains, and low-fat dairy. It was
originally designed for individuals with high blood pressure, but a couple of
randomized controlled trials have demonstrated benefits for overweight women
with PCOS.
Nutrients and( Supplements
for PCOS )
Women with PCOS may benefit from supplementing
with vitamin D and omega-3s. But other nutrients may have adverse health
effects.
Some women with PCOS are deficient in vitamin D, and women with
PCOS who are overweight are even more severely deficient (Hahn et al., 2006;
Yildizhan et al., 2009). Vitamin D deficiency may also exacerbate symptoms of
PCOS such as excess hair growth (hirsutism) and insulin resistance, as well as
increase risk for cardiovascular problems and miscarriage, which may be of special
concern for women with PCOS due to coexisting reproductive issues (Hahn et al.,
2006; McCormack et al., 2018; Thomson, Spedding, & Buckley, 2012). A 2020
meta-analysis of eleven studies found that vitamin D supplementation among
women with PCOS was associated with significantly decreased testosterone
levels, insulin resistance, and cholesterol levels, but did not have a
significant effect on BMI (Miao et al., 2020). The studies included in this
meta-analysis each used differing doses for vitamin D for different periods of
time, so future well-controlled studies are needed to determine what dose of
vitamin D is beneficial for women with PCOS. Another study published in 2020,
after this meta-analysis, found that 10,000 IU of vitamin D twice weekly combined
with clomiphene citrate and calcium may improve ovulation among women with PCOS
(see here for more on
fertility and PCOS) (Rasheedy et al., 2020). You can get only a small amount of
vitamin D from your diet, so sunshine and supplementation are often important.
