Why is this happening to me?
If this is your friendly farmer, don't listen to him.
Trying to unravel the causes of PCOS is like trying to find the start of a mobius strip, with conditions and symptoms continuously looping back on themselves. It’s a “chicken or egg” scenario, but in this case you start to wonder if maybe it was actually the chicken coop that came first. Or that bag of chicken feed. Or perhaps even the friendly farmer down the road who first put it into your head that owning chickens would be your jam.
PCOS, or polycystic ovarian syndrome, occurs when the female body produces an excess of androgens, or male hormones. This usually leads to heavy, irregular, or absent periods and can cause frustrating symptoms such as male pattern hair loss, chin hair growth, and acne. It is linked weight gain around the midsection, and often accompanies metabolic syndrome. Diabetes, hypothyroidism, and chronic inflammation are other conditions associated with PCOS. Fertility struggles are common.
The first hint in our chicken/egg/feed/farmer dilemma is insulin resistance. It is estimated to be present in 50-70% of those with PCOS. Interestingly. this doesn’t necessarily mean an F on your fasting blood sugar test; if it’s early enough in the process, the body might be overproducing insulin to compensate for blasé cell receptors, resulting in normal results. Sometimes, the only symptoms are a subtle episode of hanger in the mid-afternoon or mild hypoglycemia episodes quickly forgotten after a dive into the break room cookies.
Unfortunately, this insulin dysregulation affects the ovaries, where it encourages the overproduction of testosterone. The result is disrupted ovulatory function and -for a double whammy feedback loop- increased insulin resistance from the elevated testosterone [1]. While we can’t say which condition -if either- causes the other, it’s clearly important that anyone with PCOS pays special attention to maintaining healthy blood sugar levels through appropriate food choices.
Whoops.
Chronic inflammation is another condition linked with PCOS. As with insulin resistance, it’s hard to know where to point the finger. Many studies comparing women with PCOS against controls have found a significantly higher amount of inflammatory evidence (c-reactive protein, white blood cells, and the like) in PCOS patients, symptoms of chronic, low-grade inflammation. And the higher the levels of these markers, the more circulating androgens are found.
What! More donuts!?
While higher inflammation would be expected in overweight patients (fat tissue contributes to inflammation), the why is less straight-forward for the normal weight PCOS patients. Interestingly, it seems that sugar -glucose- plays a role again, its intake potentially inciting the inflammation response in these patients [2]. Once again, baby hands around healthy carbohydrate intake in the diet may prove to be helpful, along with an avoidance of inflammatory foods [3].
Hypothyroidism is that difficult puzzle piece that you turn every which way and can’t figure out how to fit. Statistically, there’s a connection between the two, and they share many of the same symptoms including -in some cases- polycystic ovaries [4]. Until we have more clarity around the whys and hows of this relationship, it’s worth testing for both in the case of either.
But what if you never got your first backyard chicken -or egg- and there never was and bag of feed or a friendly farmer? Just one day -WHAM- chicken dinner, served, no warning.
Lean PCOS is a lesser known subset of PCOS and that often goes undiagnosed for years. Some of the symptoms are familiar -irregular menstrual cycles, acne, and ovarian cysts- but others, such as male pattern hair growth or loss and a larger waist circumference, are notably absent.
It's hard to figure out lean PCOS when we're used to associating it with the spectrum of metabolic syndrome but, again, issues with insulin resistance seem to be at play. Studies comparing PCOS patients to controls have found that -independent of weight- insulin resistance is positively correlated to PCOS [5, 6]. For many women with lean PCOS, it may be in the early stages with deceptively normal results in a fasting blood sugar test. Two common scenarios are a body that is either hyper-sensitive to insulin, or one that overproduces it in response to food. Both scenarios can cause dramatic blood sugar drops a few hours after a meal, resulting in that shaky, unfocused, dizzy feeling that is often accompanied by fantasies of donuts.
But what about lean PCOS without insulin resistance?
When comparing lean PCOS patients without insulin resistance to obese PCOS patients, an interesting pattern emerges involving the adrenal glands and the pituitary. Higher levels of cortisol and DHEA -hormones produced by the adrenal glands in response to stress- correlate to higher levels of androgens in the body [7]. Because DHEA is a precursor to testosterone, it’s no great mystery as to how this happens, but the why remains a mystery. The result is a higher amount of androgens coming from the adrenal glands instead of the ovaries, the opposite of what's seen in more traditional cases of PCOS [8]. Linked with this scenario is a corresponding increase in luteinizing hormone from the pituitary gland, which further disrupts the hormone balance and causes irregular menstrual cycles.
It’s been theorized that stress can play a role in the development of lean PCOS. For some, symptoms begin after a period of overly restrictive dieting, over-exercising, or dramatic weight loss. These scenarios are all considered to be serious stressors by the female body, which has evolved to carefully monitor nutrients and energy for the demanding purposes of child-bearing.
Nice abs. When was your last period?
So what to do if you’re on the PCOS spectrum?
That answer is best served in a post of its own, but I’ll summarize some best practices here. And note that while there is no cure, diet and lifestyle changes can be incredibly effective for repairing the hormone balance.
As discussed above, maintaining a healthy blood sugar level and moderating the insulin response is essential. Replace refined grains and sugars with whole grains and legumes, starchy vegetables like sweet potatoes and winter squash, and occasional low-glycemic sweeteners. If you’re the nerdy type -like myself- consider buying a glucometer to monitor your body’s reaction to various carbohydrate types.
Remove inflammatory foods from you diet. Refined grains and sugars (again) along with processed seed or vegetable oils, hydrogenated oils, alcohol (red wine in moderate amounts may be ok), and MSG.
Eat more fruits, vegetables, and clean protein.
Touch base with your adrenal health. Are you wide awake in the middle of the night or exhausted throughout the morning? Are you all too familiar with those afternoon blood sugar issues? Are you struggling to lose weight despite exercise and dieting? Adrenals are complex little creatures and can’t thrive under chronic stress. This post by Diane Sanfilippo is a must-read.
Supplements to improve insulin sensitivity may be helpful, like vitamin D, chromium, or a therapeutic mix. Adaptogens like maca root, reishi, ginseng, and tulsi can help to regulate hormone production.
A gut healing protocol can be incredibly healing. By overhauling the diet and restoring a healthy microbiome, unidentified root causes can be addressed and will give the body to thrive. Consider an anti-inflammatory, nutrient-dense, low-sugar challenge like the Whole30, GAPS diet, or the 21 Day Sugar Detox.
Reduce stress as much as possible. Meditate. Walk. Sing. Whatever. Find yours. Also avoid stimulants like afternoon coffee or daily cocktails. These will mask unbalances that are better confronted and repaired.
Above all, give it time. PCOS is just a piece to a larger health and wellness puzzle. Don’t be discouraged by stubborn symptoms or an uncooperative body. Just focus on your whole health, do what you love, and be patient.