Polycystic Ovarian Syndrome (PCOS): No. 1 Cause of Infertility?

Causes and Risk Factors

While the exact cause of PCOS is somewhat unclear, there are a few theories on how it develops. These are probably not a “one-size-fits-all” answer, but rather interact with each other to initiate the development of this disease. The main causes and risk factors are thought to include:

• Altered action of the luteinizing hormone (LH)
• Insulin resistance
• A genetic predisposition to hyperandrogenism (this may be reflected diagnostically by subclinically high levels of androgens)
• Family history of PCOS
• Smoking
• Excessive alcohol consumption
• Sedentary lifestyle
• Epilepsy and/or use of valproic acid to treat epilepsy
• Type 1, type 2 and gestational diabetes (it’s unclear if diabetes leads to PCOS, or if this occurs in reverse order, but both are probably true)
• High birth weight (particularly when born to an obese mother)
• Premature puberty
• Acanthosis nigricans (a skin disorder)
• Metabolic syndrome

It’s been commonly thought that obesity is a risk factor for PCOS. However, clinicians seem to agree, based on recent research, that while losing weight is one major way to naturally treat polycystic ovarian syndrome, the weight itself probably isn’t a direct cause. It may bring on symptoms faster, though.

A high percentage of PCOS patients deal with weight gain at some point, but we now know that there are plenty of women who are normal weight, or even underweight, who also develop hormonal disruptions that lead to polycystic ovary syndrome. PCOS patients come in all shapes and sizes, and their histories can be very diverse, which makes treating this condition even more complicated.

A 2017 study led by the University of Birmingham revealed that a class of androgens, known as 11-oxygenated C19 steroids, contributes significantly to androgen excess in women with PCOS, while previous research has primarily focused on one androgen: testosterone.

PCOS was also thought to be more hereditary than it actually is. While twin studies have indicated there is a strong genetic component to developing polycystic ovaries, other information points to only up to a 32 percent chance of immediate relatives also having the condition.

Diagnosis

There’s actually some controversy surrounding the criteria used to determine a PCOS diagnosis and even how to label the condition. In fact, some polycystic ovarian syndrome experts have questioned whether or not changes to polycystic ovary syndrome criteria have led to an over-diagnosis of the condition among reproductive-age women. In addition, as noted previously, treatment options can vary.

Multiple criteria for diagnosing PCOS exist, all of which require different combinations of the following three symptoms for a positive diagnosis:

1. Androgen Excess

An excess of androgens is commonly caused by PCOS (or vice-versa). These include testosterone, androstenedione, dihydrotestosterone (DHT), dehydroepiandrosterone (DHEA) and DHEA sulfate (DHEA-S). These levels are sometimes sub-clinical (not obvious on a blood test) in PCOS patients, but typically need to show up at significant levels for a doctor to include it for a diagnosis.

2. Ovulatory Dysfunction

One of the most well-known effects of PCOS is problem with ovulation. This can manifest as oligomenorrhea (irregular periods) or amenorrhea (missing periods). Many women with PCOS experience abnormally heavy, short or long menstrual cycles, which also falls under the heading of ovulatory dysfunction.

3. Polycystic Ovaries

This may seem obvious, but not every diagnostic criteria actually requires a definitive discovery of polycystic ovaries, as they claim that the possibility of polycystic ovaries based on the first two criteria is enough for the syndrome to manifest itself.

However, many women with PCOS multiple ovarian cysts that can be identified on a vaginal ultrasound. There have been personal reports from women whose ultrasound technicians pointed out their ovaries were partially and even completely obstructed on ultrasound by the large number of ovarian cysts they had.

Depending on what doctor you see, they may use different criteria to diagnose you. The three basic options include:

• National Institute of Health Criteria (1990): Patient must have both androgen excess and irregular periods
• Rotterdam Criteria (2003): Patient must have any two of the above three symptoms
• Androgen Excess and PCOS Society (2009): Patient must have androgen excess plus either ovulatory dysfunction OR polycystic ovaries

According to The Endocrine Society, Rotterdam criteria is the best option for diagnosis. Some clinicians estimate that this may nearly double the number of PCOS diagnoses from either of the other two methods.

The guidelines for the Rotterdam criteria note that excess androgen is a key factor in presentation of the condition in adolescents.

Conventional Treatment

According to the American Family of Family Physicians, treatment for PCOS should be “individualized,” meaning it matters how old you are, how severe your symptoms are and whether or not you’re trying to get pregnant for a physician to advise a treatment plan.

They also recommend patients be tested for blood pressure levels, lipid levels (for cholesterol, triglycerides, etc.), glucose tolerance, depression and sleep apnea.

Depending on whether or not you want to get pregnant, conventional medicine dictates one of the following treatment plans:

If You’re Trying to Get Pregnant

Natural Remedies

PCOS is a complex condition, and the road to resolving the hormonal imbalances that cause it are not the same for every woman. Practitioners, and women with polycystic ovarian syndrome, both agree that there isn’t a “one size fits all” approach that balances hormones best. Kate Kordsmeier of Root + Revel recounted her personal experience in reversing PCOS naturally without medications in a guest post.

Diet isn’t everything, and other lifestyle factors — especially stress, but also things like meal timing and level of exercise — all play an important role in a woman’s reproductive system. While it might seem complicated, the best options for moving forward for women with different types of polycystic ovary syndrome all fall within the same general categories, focusing on all aspects of health: mainly, eating a balanced diet, maintaining an appropriate body weight and eliminating as much physical and psychological stress as possible.

Here are some of the most well-researched natural remedies for PCOS symptoms.

1. Give Your Diet a Makeover

The standard American diet offers little in the way of nutrition, particularly for women with PCOS who are often insulin resistant. While the standard recommendation for obese women has been to eat a low-fat and/or low glycemic index diet, these may not actually be beneficial for those with polycystic ovarian syndrome.

For instance, did you know that a diet high in healthy fats and low in carbohydrates can actually result in more weight loss? In morbidly obese subjects (both men and women, not directly those with PCOS), this type of diet led to over doubled weight loss when compared to a low-fat diet, stunning researchers in a 2003 clinical trial.

This type of diet is known as a keto diet, or ketogenic diet. Originally developed for children with epilepsy by researchers at Johns Hopkins Medical Center, this diet focuses on drastically reducing carbohydrate intake, getting the majority of your calories from healthy fats and some from protein. This diet induces a process called ketosis in which your liver begins producing ketones for you to metabolize as energy, rather than burning glucose. When you’re in ketosis, your body burns fat more quickly. This diet has also been heralded as a remedy for brain fog and is currently the focus of a great deal of research surrounding mental health and disorders.

There are multiple benefits of the ketogenic diet for PCOS. For one, women with PCOS are at a higher risk for depression, so the mental health benefits of keto may help offset some of that risk. For another, doing keto is often a fast, safe and effective way to lose a lot of weight in a short amount of time, which is associated with an improvement in fertility and other PCOS symptoms.

Third, this diet causes your body to utilize ketones, not glucose, which means it’s a powerfully potent remedy for insulin resistance, which is also associated with fertility issues. Reducing carbohydrate intake has already been shown to improve insulin sensitivity in women with PCOS.

Another dietary model that may work those with PCOS is an anti-inflammatory diet. Naturally anti-inflammatory foods include vegetables, fruits, grass-fed/pasture-raised meats, wild-caught fish (like salmon), nuts/seeds (like chia, flax, hemp, almonds and walnuts) and unrefined oils/fats (including coconut oil, olive oil and avocado). This type of diet seems to reduce some of the metabolic symptoms of PCOS and results in weight loss.

In general, any lifestyle-modifying diet that effectively allows a patient with PCOS to lose weight is going to have some benefit in restoring fertility and improving other symptoms of the condition, even when you lose only five to 10 percent of your total body weight.

2. Get Enough Rest

Sleep is crucial for cell regeneration, hormone production, stress control and even weight management. In fact, sleep deprivation can have the same negative effects on health and hormones as a lack of activity and a poor diet can. Women with PCOS are more likely to have sleep disturbances, and at least one study has found that this may due to an overproduction of melatonin.

According to a large cross-sectional study, PCOS sufferers who get less sleep are at more risk for mental issues and insulin resistance. These women are also more likely to develop obstructive sleep apnea.

Consistently going without enough sleep increases stress hormones in the body, including cortisol, and changes levels of hormones that control your weight and appetite, including insulin and ghrelin. The more stressed you are, the more sleep you likely need — but the general recommendation that works well for most people is aiming for seven to nine hours each night. Some women with polycystic ovary syndrome may need upwards of nine hours consistently.

3. Exercise in an Appropriate Way

If you have a predisposition to developing hormonal imbalances, keep in mind there’s a fine line between too little activity and too much. Generally speaking, women’s bodies are more susceptible to hormonal changes when exercise is increased beyond healthy levels. For example, “female athlete triad” is a condition that can contribute to PCOS. It’s caused by too much exercise coupled with a restrictive diet and too few calories. Female athletes also can be more susceptible to irregular periods, according to multiple studies.

However, there are many benefits of exercise to consider beyond this one condition. While those with polycystic ovarian syndrome might not be able to lose weight through exercise as easily as others, there is evidence that, no matter the type of exercise you choose, exercising with PCOS might improve fertility markers, insulin resistance, inflammation and weight.

4. Avoid Exposure to Endocrine Disruptors

Endocrine disruptors are chemicals that interfere with the production, release, transport, metabolism or elimination of the body’s natural hormones. Women with hormonal disorders like PCOS are very sensitive to this type of interference, and high levels of endocrine disruptors such as bisphenol A may have an impact on the androgens in their bloodstream.

Endocrine disruptors in plastics (BPA, DEHP and DBP) might even influence the epigenetics of people with reproductive disease and obesity to make it more likely that people pass the disorders to their children.

In all, the endocrine disruptors that affect PCOS seem to include:

• Pesticides
• Bisphenol A
• Phthalates
• Dioxins
• Phytoestrogens
• BPA
• DEHP
• DBP

5. Supplement with Inositol

One particularly significant natural method of treating PCOS is inositol, a sugar alcohol chemical compound found in fruits, beans, grains and nuts (although it is not always bioavailable in these foods if presented with phytates). In nutrition, inositol is present in the highest levels in cantaloupe and oranges.

Most sources investigate inositol in supplement form, although the specifics can get a little tricky as there are two types of inositol: myo-inositol and D-chiro-inositol. However, the research seems to support that inositol can greatly improve PCOS symptoms. Multiple studies have shown that supplementation may improve insulin resistance, decrease male hormones in the bloodstream, and lower blood pressure and high triglycerides. The recommended dosage for naturally treating polycystic ovarian syndrome is a 40:1 ratio of myo-inositol to D-chiro-inositol, typically 2000:50 grams or 4000:100 grams.

Most notably, inositol seems to promote ovulation, which, in turn, may support fertility. In one study, only 6 percent of control group participants experienced menstrual cycles versus 86 percent in the inositol group, results that seem to be supported by follow-up research.

6. Try Acupuncture

While many might be skeptical, there is evidence that acupuncture may function as a very useful complementary treatment for women with PCOS. A review in 2011 of four human clinical trials of acupuncture for PCOS found that:

Acupuncture therapy may have a role in PCOS by: increasing of blood flow to the ovaries, reducing of ovarian volume and the number of ovarian cysts, controlling hyperglycaemia through increasing insulin sensitivity and decreasing blood glucose and insulin levels, reducing cortisol levels and assisting in weight loss and anorexia.

Another acupuncture option that shows promise is electro-acupuncture. Also published in 2011, a report from the Osher Center for Integrative Medicine in Sweden discovered that combining electro-acupuncture (EA) with exercise resulted in improved sex hormone levels, menstrual frequency and hyperandrogenism. EA alone outperformed exercise in this clinical trial.