Here is your complete guide from PCOS to wellness. Learn about PCOS, the symptoms, how it is diagnosed and how it is treated.
Understanding Polycystic Ovary Syndrome (PCOS)
Polycystic ovary syndrome (PCOS) is a significant women’s health issue with reproductive, metabolic and psychological features.
PCOS is the most common endocrine disorder among women of reproductive age, affecting 8-13% of reproductive-aged women with up to 70% of affected women remaining undiagnosed. It is most commonly diagnosed in those aged between 18 and 44 years old. The causes of PCOS are multifactorial, and is related to genetics and environmental factors.
There are many treatment options available for PCOS. There’s no one-size-fits-all approach to treatment, so your health practitioner will work with you to come up with a plan that’s best suited to your needs. Some treatments focus on managing the symptoms of PCOS, while others aim to restore normal hormone levels and improve fertility.
What are the symptoms of PCOS?
There are a number of symptoms that women with PCOS experience that affect a wide variety of systems in the body. PCOS symptoms can include
- Irregular menstrual cycles
- Pregnancy complications – including gestational diabetes
- Increased risk of endometrial cancer (often before menopause)
- Insulin resistance (IR)
- Metabolic syndrome
- Type 2 diabetes (DM2)
- Cardiovascular risk factors
- Weight gain
- Body image issues
Skin and hair features:
- Excess hair growth on the face, chest, or back (hirsutism)
- Hair thinning or hair loss
- Acanthosis nigricans (pigmentation in body folds and creases – especially armpits, groin and the neck)
Because the symptoms can affect multiple body systems, it can be difficult to identify. If you experience two or more of these symptoms, it’s important to see your doctor for a diagnosis.
There is no single test to identify PCOS. It is diagnosed by a physician after a physical exam and blood tests. Sometimes you may also need an ultrasound to assist with diagnosis. The Rotterdam Criteria is the most widely recognized criteria for diagnosing PCOS by doctors and researchers. The Rotterdam criteria requires 2 of the following criteria to be met for a diagnosis of PCOS;
- irregular menstrual cycles
- high testosterone levels – on blood tests
- high testosterone features – acne and/or facial hair growth
- polycystic ovaries on ultrasound scan
The diagnosis of PCOS includes ruling out other conditions, especially among younger women, who may have irregular periods and acne as part of puberty where their hormones naturally are in the process of developing their rhythms. In this case it is recommended ultrasound is not used for young women who started their menstrual periods within the past 8 years as they will have multiple follicles which is normal for their stage of ovary maturation.
It is likely your doctor will do other testing to make sure there is not another reason for your symptoms including thyroid disease.
Early detection is key not only for normalizing menstrual cycles but also for protecting against related risks such as infertility, diabetes, endometrial cancer and cardiovascular disorders. Women with PCOS should plan for treatment and address individual needs.
Should AMH be used to diagnose PCOS?
AMH tends to be elevated in some women with PCOS. However AMH can also reflect a good ovarian reserve and so cannot distinguish between this and someone who is creating multiple follicles in their ovaries. For this reason it is not yet an adequate diagnostic test for PCOS although it may give your doctor more information about your clinical condition.
Insulin Resistance: the key metabolic problem
Insulin resistance is a major feature of polycystic ovary syndrome, meaning as well as being an endocrine condition, it is a metabolic condition. It affects 75% of women with a BMI 20-25 and 95% of women with a BMI over 25 with PCOS. Insulin resistance means that even though there is insulin present in the body, the body cannot use it efficiently to store sugar in the body. This means the body must produce more insulin to reduce blood sugar levels and also that the blood sugar levels tend to be higher. The higher insulin levels contribute to increased fat storage by the body and contributes to weight gain.
Insulin resistance is a key issue in PCOS because of the interplay between male androgenic hormones. The elevated testosterone hormones increase the amount of insulin your body needs to produce in order to maintain normal blood sugar levels. When insulin levels are high for long periods of time, it can lead to type 2 diabetes and other health problems like heart disease and obesity. Additionally higher insulin levels stimulates higher levels of testosterone to be produced by the ovaries.
Although PCOS is a metabolic disorder of insulin resistance, the current testing for insulin resistance is inadequate, however some clinicians measure fasting insulin level and studies looking at lifestyle interventions have shown a reduction in fasting insulin levels due to changes in exercise and diet.
When insulin resistance becomes significant enough it also influences blood sugars. This is where testing
- HBA1C – which measures how much sugar is attached to hemoglobin in your blood can be useful. As this goes up, insulin resistance is increasing. It can indicate pre-diabetes and diabetes.
Other tests that indicate problems with insulin resistance include;
- fasting blood glucose
- oral glucose tolerance test.
Insulin resistance can be influenced by other things than testosterone levels in both positive and negative ways. For example strategies to decrease insulin resistance include;
- intermittent fasting
- resistance training, especially high intensity interval training (HIIT)
- whole food plant-based diets such as Mediterranean diet
Conversely things that promote insulin resistance include
- further weight gain
- lack of movement/exercise
- depression (Watson 2021)
- some medications.
If your medications contribute to weight gain they may be able to be changed to ones that are weight-neutral. If you experience depression this can affect your energy levels, motivation in negative ways so seeking treatment for this can help.
PCOS to wellness: standard Medical treatments
It may surprise you to see that the first line standard treatments for PCOS to wellness are lifestyle interventions – diet and exercise, not medications and they are supported with good evidence.
A systemic Cochrane review of lifestyle interventions in women with PCOS found that diet and exercise was effective at;
- reducing testosterone
- reducing facial hair growth
- reducing waist circumference
- reducing waist to hip ratio
- reducing fasting insulin
- improved oral glucose tolerance tests
- weight reduction.
The international guidelines for polycystic ovarian syndrome recommend eating a healthy diet and exercising regularly as two important lifestyle changes that can help to stabilize PCOS symptoms and improve insulin resistance. In addition, getting enough sleep can also help to regulate your hormone levels and improve your mood. All of these changes can be made without additional treatment or medication needed.
Making dietary changes is often one of the first steps people take to improve their health. This is especially true for women with polycystic ovarian syndrome (PCOS), as diet influences insulin sensitivity, weight and diabetes.
Recent research from 2019 examined the diets of 112 women with PCOS and compared this to 112 women without PCOS (controls). They looked at the dietary differences between diets and showed that despite consuming the same total energy or calories, the same amount of protein and the same amount of carbohydrates the composition of the diet varied significantly.
Women with PCOS consumed
- fewer nuts
- less fish or seafood
- less legumes (beans and lentils)
- less olive oil
- less fiber
- more simple carbohydrates i.e. refined sugars found in candy, cakes, cookies, potato chips etc.
- less complex carbohydrates i.e. carbs in whole fruit, veg, grains and legumes
- more fat, including saturated fat
- less monounsaturated fats, polyunsaturated fats and omega-3 fatty acids
Additionally the study compared the women with higher biochemical testosterone levels with those with lower testosterone levels and found that women with PCSO with the highest testosterone levels:
- higher weight,
- higher CRP levels (inflammation),
- higher insulin resistance,
- higher fasting blood glucose.
These findings suggested that these women with higher testosterone hormonal imbalances had more severe metabolic symptoms of PCOS.
The diets varied between women with PCOS with low testosterone and high testosterone. Women with PCOS and lower testosterone levels consumed;
- fewer calories
- fewer carbohydrates, especially less simple carbohydrates
- more fiber
- less fat, especially saturated fat and omega-6 fatty acids
- more monounsaturated and polyunsaturated fats
These dietary patterns are reflective of the Mediterranean diet which is a type of whole-food plant-based diet. It is based on fruit, vegetables, whole grains, unsaturated fats including olive oil and moderate wine consumption.
Further analysis of the study showed that women with PCOS whose dietary patterns highly reflected a Mediterranean diet had:
- lower CRP levels
- lower insulin resistance
- lower testosterone levels
- less facial hair,
compared with women who had alternate dietary patterns.
Current research is moving away from analysis of individual foods or nutrients and more towards dietary patterns. This study is a clear indication that confirms what is known about the metabolic nature of this condition: Insulin resistance is managed best through a diet that is
- low in saturated fats – less fried, processed foods and meats
- higher in unsaturated and omega-3 fats,
- low in high-glycemic index carbs (i.e. refined or simple sugars)
- high in fiber – including nuts and legumes.
A variety of whole-food plant-based diets meet this criteria including the Mediterranean diet, DASH diet, a whole-food pescatarian or vegetarian or vegan diet. These diets not only have benefits on the body directly through improved nutrient profile, but also due to positive effects on the gut microbiome.
A new style of eating is a change in lifestyle. It can take time as it can involve a new set of skills of shopping, preparing and cooking food. Spend some time investigating the whole food plant-based diets suggested above to discover the best plan for you.
Changes do not need to be sudden or radical at first. Small steps could include
- Changing your breakfast,
- Substituting one meat meal per week with legumes or
- Quitting soft drinks
- Eating an extra serving of vegetables with your main meal.
- Cooking more food on the weekend so you eat less takeout during the week.
Even small changes can have a big impact on your health and reproduction. Simple changes to your diet also improve your overall health and reduce the risk of other complications, such as type 2 diabetes and heart disease.
Exercise improves insulin resistance. Exercising skeletal muscle drives blood sugar into muscle cells making the cells more responsive to insulin. High intensity interval training (HIIT) is a good method to exercise skeletal muscle, and especially in people with insulin resistance.
HIIT exercises a muscle group for a short time ie 30-60 seconds, but at maximal capacity and then has a brief recovery period. A recent systematic review published in 2021 looked at the effect of high intensity interval training on metabolic markers in women with PCOS. The conclusion was that in women with PCOS, HIIT was effective at both
- reducing insulin resistance, and
- reducing body mass index (BMI).
Recommendations from the international guidelines for PCOS encourage
- 50 mins moderate exercise, 5 x per week or
- 30 mins vigorous exercise, 5 x per week.
For those who have not done exercise in some time, this can seem impossible if not terrifying. You can build up your fitness over time. You could begin with step counting with a fitbit or smartwatch, starting at 3,000 and aiming for 10,000 steps per day.
For those new to HIIT, trying a 7 minute workout such as this – and doing the low impact version is a good way to start. You could use this video for 5 days a week and then move to another one. As you become more confident you can try the more aerobic version.
Medications for non-fertility symptoms
There are a number of medications used to treat symptoms of PCOS that do not address the underlying cause of PCOS. However, metformin is really a key medication for PCOS to wellness because it reduces insulin resistance which drives weight gain infertility and other complications like diabetes.
Combined oral contraceptive pill (COCP)
The oral contraceptive pill is used to create a regular withdrawal bleed (not a period and not ovulation) and to counter elevated testosterone level. However it cannot be used when a woman is attempting to become pregnant. It does come with side effects and a particular COCP, 35 microgram ethinylestradiol plus cyproterone acetate (Diane 35) is not recommended to be used as a first line treatment in women with PCOS due to side effects including blood clots.
Metformin is a biguanide originally derived from the plant Gelega officinalis (French lilac) and now synthetically made. It’s main mechanism of action is that it reduces glucose production by the liver. It is recommended to be used alongside lifestyle changes in women with PCOS to treat weight, metabolic and hormonal outcomes.
It can be used while trying to get pregnant. It usually enhances weight loss. Compared with COCP it has better weight loss and improved cholesterol.
The most common side effects are nausea, diarrhea, stomach ache and loss of appetite. The best way to get around this is to start with a low dose and increase slowly over time. Most people are able to tolerate at least some metformin this way.
Metformin does inhibit B12 absorption from the stomach with long-term use so you should ensure you have your B12 and blood count checked annually. Alternatively you could take a sublingual (under the tongue) or intra-muscular B12 supplement to ensure adequate B12.
It less commonly also inhibits folate absorption so ensuring adequate folate in the diet through leafy greens is important. This can also be supplemented if your levels drop low.
Flutamide, finasteride and spironolactone are anti-androgens used to treat excess facial hair and hair thinning if the combined birth control pill is not tolerated. They block the effect of testosterone. However they do not treat the root cause – ie the insulin resistance so does not improve your blood sugars or help to lose weight.
You do not want to use these preconceptionally as if you fall pregnant they can have adverse hormone effects on the developing fetus.
Sibutramine and Orlistat are two weight-loss medications reviewed by PCOS international experts and the evidence was not substantive for weight loss, improving symptoms or metabolic measures.
Nutrients and Supplements for PCOS
PCOS is a hormone disorder that can cause problems with a woman’s menstrual cycle, fertility, and metabolism. In addition to lifestyle changes of diet and exercise some women with PCOS seek to improve their PCOS symptoms naturally and may benefit from supplementing with certain nutrients and supplements. This is just a short list of some of the nutrients and supplements used in PCOS. (see here for a complete overview of nutrients and supplements for PCOS).
- Fish oil/omega-3 fatty acids
We hope you found this information helpful and wish you well on your journey from PCOS to wellness!
Barrea L, Arnone A, Annunziata G, et al. Adherence to the Mediterranean Diet, Dietary Patterns and Body Composition in Women with Polycystic Ovary Syndrome (PCOS). Nutrients. 2019; 11(10):2278. https://doi.org/10.3390/nu11102278
Farshchi H, Rane A, Love A et al. Diet and nutrition in polycystic ovary syndrome (PCOS): Pointers for nutritional management, Journal of Obstetrics and Gynaecology, 2007, 27:8, 762-773, https://doi.org/10.1080/01443610701667338
Kim J, Ahn CW, Fang S, et al. Association between metformin dose and vitamin B12 deficiency in patients with type 2 diabetes. Medicine (Baltimore). 2019;98(46):e17918. doi:10.1097/MD.0000000000017918
Helena J Teede, Marie L Misso, Michael F Costello, et al. International PCOS Network, Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome, Human Reproduction, 2018; 33(9):1602–1618 https://doi.org/10.1093/humrep/dey256
Santos I, Nunes F, Queiros V et al. Effect of high-intensity interval training on metabolic parameters in women with polycystic ovary syndrome: A systematic review and meta-analysis of randomized controlled trials. PLoS One. 2021 Jan 19;16(1) doi: 10.1371/journal.pone.0245023.9
Stepto NK, Cassar S, Joham AE, et al. Women with polycystic ovary syndrome have intrinsic insulin resistance on euglycaemic-hyperinsulaemic clamp. Hum Reprod. 2013;28(3):777-784. doi:10.1093/humrep/des463
Watson KT, Simard JF, Henderson VW, et al. Incident Major Depressive Disorder Predicted by Three Measures of Insulin Resistance: A Dutch Cohort Study. Am J Psychiatry. 2021;178(10):914-920.