But I’m not overweight! How could I have PCOS
Polycystic Ovarian Syndrome (PCOS) affects about 17.8% of women of childbearing age and describes a cluster of symptoms that includes absent or irregular periods, facial hair, acne, hair loss and infertility. Because blood sugars and insulin play a role in the disease, many people think it only occurs in obese and overweight women but this is not necessarily true. In reality, about 20-50% of women with PCOS are normal or even underweight. This is not a surprise as I’ve seen many healthy weight women come through the doors of my New York City practice with PCOS. If weight seems to be such an important predictor in the onset and progression of PCOS, why would lean women also susceptible?
High Luteinizing Hormone (LH)
Now lets talk a little bit about how your menstrual cycle works. A hormone that you might not be familiar with, LH, is released from the anterior pituitary gland and stimulates our ovaries to produce testosterone. Then follicle stimulating hormone also from our anterior pituitary stimulates aromatase to convert testosterone to estrogen. The increase in estrogen triggers a surge of LH and bam we have ovulation. With the release of the egg, next progesterone levels rise. If fertilization doesn’t occur, then our uterine lining sloths off, hormone levels drop and the cycle starts again. So if we want LH levels to increase why would high LH levels be a problem and lead to PCOS? It appears that women with PCOS, particularly lean women, may have hypothalamic-pituitary defect that results in increased release of LH. Why this is a problem is too much LH causes too much testosterone to be produced leading to hair loss and acne. The excess testosterone also leads to more estrogen, which is made worse when ovulation doesn’t occur. If we don’t ovulate our body doesn’t increase progesterone levels. The end result is a high estrogen to progesterone ration. As a consequence anovulatory cycles persist and we develop incredibly painful heavy periods. Another issue is if LH levels are chronically elevated our body doesn’t perceive the normal LH surge so ovulation does not occur.
In this case, women need to address both the elevated LH levels and enhance the conversion of testosterone to estrogen as well as overall hormone clearance. In my naturopathic practice, I have found botanical medicine can be a great tool to address all of theses. My favorite formula by far is licorice and peony as it can both decrease LH and testosterone. You might associate with black cohosh with menopause but it also decreases LH while increasing progesterone and has be helpful to improve outcomes with IVF. One of the most easily to use herb is green tea which blocks 5α-reductase, the enzyme that converts testosterone to its more active form and increases Sex Hormone Binding Globulin that binds to excess testosterone.
Women with PCOS don’t necessarily have more stress than the rest of us but their adrenal glands may act a little different. In general, excessive stimulation of adrenal glands in response to stress increases androgen output. This is one of the reasons you might experience more breakouts after preparing for a big presentation at work. For women with PCOS, it’s as if stress puts the adrenal glands into overdrive pumping out more androgens and cortisol than the average woman, though their overall HPA-axis function is the same. It is still unclear why the response is so exaggerated in these women. Though some testosterone is produced, the main adrenal androgen is DHEA which is the precursor hormone for all our hormones of reproduction. If I suspect that my patient may have PCOS due to adrenal dysfunction, I will have her DHEA-S levels tested in addition to her standard hormone panel.
This is why stress management and reduction techniques are key for women with PCOS. If they are not constantly under stress, their adrenal glands receive less stimulation and produce less adrogens. By far I find breathing techniques like this one a great place to start. To help reduce cortisol and stress induced HPA axis activation, I will also often prescribe phosphatidylserine. I find it to be especially helpful when combined with L-theanine, a component of green tea. My patients like this combination as well because they sleep easier and deeper. Rhodiola is another great addition for lowering cortisol and tonifying the HPA axis.
Insulin Resistance is not just due to obesity
Though insulin resistance is one of leading factors in the development of PCOS, it was long believed that it was not the cause for PCOS in nonobese women. This would be further from the truth. Many normal weight women with PCOS like their overweight counterparts have an intrinsic form of insulin resistance specific to PCOS meaning that their tissues’ ability to respond to insulin is impaired. With less tissues absorbing glucose and insulin constantly being released, hyperinsulinemia and elevated blood glucose develop. Why this happens is a result of a combination of genetic and lifestyle and dietary factors. The end result is that elevated insulin levels stimulates ovarian cytochrome P450c17 activity, which is an enzyme key in androgen production and explains insulin’s involvement in the condition. Insulin lowers Sex Hormone Binding Globulin (SHBG)which increases levels of circulating free testosterone. With insulin resistance, we also see higher levels of gonadotropin-releasing hormone (GnRH) leading to believe or not more LH another thing we don’t want.
Just as the case with my overweight patients, my normal weight patients need to get their blood sugars under control and improve insulin response. At the beginning of a naturopathic PCOS support program, I will have my patients’ blood glucose, insulin and HA1C levels tested so we can have a therapeutic baseline. To keep blood sugars stable a healthy balanced whole foods diet is crucial. This diet should consist of lean protein, healthy fats, vegetables, and a small amount of whole grains, along with the elimination of refined grains, sugar, dairy products, and sometimes gluten. Fruit can be tricky with these patients due to its high fructose content so I encourage them only in moderation. Diet alone in many cases won’t be sufficient, so I will also add chromium, alpha-liopic acid and inositol to improve insulin resistance and reduce blood glucose. Of these I have found the chiro and myo forms of inositol to be the most effective in bringing down insulin levels. Many studies have shown the chiro and myo forms of inositol to improve ovulatory function and even help in reducing obesity by regulating glucose uptake and glycogen synthesis.
The take home is that PCOS is not just matter of weight and could affect any women of any weight. If you are having erratic cycles, acne, facial hair or hair loss you might want to ask your primary care doctor or gynecologist about PCOS. If you know you have PCOS, you may want to consider any of these or combination of these factors and start addressing them in a natural way.