Guest blog by Dr. Gina Neonakis, a licensed Naturopathic Doctor.
Polycystic Ovarian Syndrome, commonly known as PCOS is a metabolic condition that affects around 10% of reproductive aged women. Often times, women with this condition experience fertility challenges as menstrual cycles and ovulation can be irregular. However, women with PCOS can get pregnant. Working with a practitioner, such as a Naturopathic Doctor who understands the underlying causes of PCOS can reduce your symptoms and optimize your chances of conceiving.
Many people think of PCOS as being a hormonal imbalance. However, this imbalance is often driven by underlying factors such as insulin resistance and chronic low-grade inflammation. Therefore, when it comes to treatment options, we are often targeting metabolic dysfunction along with hormonal imbalances to improve the overall symptom picture and optimize fertility.
The Rotterdam criteria is the most widely accepted tool for diagnosing PCOS. In order to meet the diagnosis, you must meet 2 of the following criteria:
- Amenorrhea or Oligomenorrhea
- Amenorrhea is the absence of a menstrual cycle for more than 3 months.
- Oligomenorrhea is irregular menstrual cycles that are longer than 35 days. This means there are 35 or more days from day 1 of your period until your next period begins.
- Hyperandrogenism (elevated androgens) – this can be biological or clinical
- Biological – increased androgens on blood testing. This can include elevated testosterone, androstenedione or DHEA
- Clinical – having visible symptoms of elevated androgens such as acne, oily skin, hair loss on the scalp or hirsutism (abnormal hair growth in areas such as the chin, face, between the breasts or abdomen).
- Polycystic ovaries on transvaginal ultrasound – This used to be characterized by 12 follicles per ovary, however due to advancements in technology we often use 25 follicles or an ovarian volume of 10mL or more.
- It is normal to have multiple follicles growing at the same time in a single ovary. As technology improves, these parameters change to avoid over-diagnosing this condition.
What are the symptoms of PCOS?
PCOS can present in different ways. Women may be overweight or lean, have regular or irregular cycles and may or may not have signs of high androgens such as hirsutism or acne. There are different phenotypes or varieties of PCOS, where different combinations of symptoms can occur. Potential symptoms include:
- Irregular or absent menstrual cycles
- Acne or oily skin
- Hair loss on the scalp, particularly in the front
- Course hair growth in areas such as the chin, chest, abdomen and inner thighs
- Skin tags
- Darkened patches of skin under the armpits or behind the neck
- Weight gain
- Anxiety or depression
The underlying causes of PCOS
Insulin Resistance is one of the most common underlying factors that drives PCOS. This occurs when baseline levels of insulin are elevated and insulin receptors are less sensitive than they should be. With less sensitivity, insulin cannot move glucose into the cells efficiently which can lead to high blood sugar, elevated triglycerides and cortisol, inflammation and an increased risk of diabetes. Elevated insulin also causes the ovaries to produce more androgens, which can inhibit ovulation.
Signs of insulin resistance include:
- Skin tags
- Acanthosis nigricans – dark patches of skin, usually around the armpits or on the back of the neck
- Difficulty losing weight, or weight gain
- Feeling shaky or light-headed when you skip a meal
Inflammation is often found in PCOS patients and can contribute to androgen production and insulin resistance. It is important to rule out autoimmune conditions and reduce inflammation when trying to conceive, as this impacts implantation and pregnancy maintenance. Often times, inflammation can be related to gut dysfunction.
Adrenal dysfunction, which is often a result of chronic stress can be a common contributing factor in PCOS due to its effects on blood sugar. The adrenals are two small glands that sit on top of our kidneys and secrete cortisol and adrenaline in response to stress. Cortisol increases our blood sugar as a survival mechanism, which historically was used as energy to run from a threat. Today, we may not be running away from a bear, but our body still responds the same. The constant stress that we experience from daily living results in elevated cortisol, which increases blood glucose. This excess glucose is often not utilized and is stored as fat, and can lead to elevated triglycerides and inflammation. Additionally, more insulin is released to deal with the blood sugar and over time this leads to insulin resistance, which is a common underlying cause in PCOS.
Hormonal imbalances are a common finding in PCOS, and they are often exacerbated by other underlying imbalances. Often times, there are elevated androgens (such as testosterone or DHEA) due to increased production from the adrenals and ovaries. This can be driven by insulin resistance. High androgens contribute to symptoms such as acne, hair loss and hirsutism. Additionally, progesterone can be low because it is only secreted when ovulation occurs, which can be delayed or irregular in PCOS. Therefore, by supporting blood sugar regulation, adrenal function and ovulation we are indirectly treating hormonal imbalances.
How do I know if I’m ovulating?
A big piece of the puzzle when trying to conceive is understanding when, or if you ovulate. You can still have a period without actually ovulating. This is known as withdrawal bleeding. Tracking ovulation is important because often times women with PCOS have longer cycles, meaning ovulation will occur later. LH strips are not the most useful tool in PCOS because LH is often chronically elevated, meaning tests can show up as positive at any point in the cycle.
Basal body temperature (BBT) tracking is a great tool to predict ovulation. Your body temperature rises slightly 1-2 days AFTER ovulation, due to progesterone. This means BBT isn’t helpful to tell you when you will ovulate, but it can confirm ovulation and help predict the window for future cycles.
First thing in the morning before you get out of bed, place a thermometer under your tongue and track the temperature reading. It is best to use a thermometer that records to 2 decimal places (ex: 36.57, rather than 36.5) because the shift will be very slight. You can track by using an app such as Kindara or Fertility Friend, or just a pen and paper. Around mid-cycle, you will see an increase in temperature, and it should stay elevated until your period. When you see the temperature spike, count back 1-2 days and this is often when ovulation occurred.
After a few cycles, you can determine which day you typically ovulate on based on previous charts. You are most fertile for around 5 days, so it is best to have intercourse from 3 days before ovulation until 2 days afterwards if you are trying to conceive.
Treatment options when trying to conceive with PCOS
Treatments are dependent upon your unique case and which factors are most prevalent for you. Examples of common treatment options include:
- Metformin – this is a drug that is often prescribed to patients with diabetes. It can help with insulin resistance and ovulation, but there are also more natural alternatives that have been shown to have similar benefit with less side effects.
- NAC – Studies have shown that n-acetylcysteine (NAC) is comparable to metformin at improving androgen levels, insulin resistance, lipid profiles, menstrual regularity and egg quality1,2, 3.
- Myo-inositol – can support insulin resistance, embryo quality, ovulation and frequency of menstrual cycles4,5. One study showed that myo-inositol was comparable to metformin at improving insulin sensitivity and menstrual cycle length, but with less side effects6.
- Vitamin D – low levels are associated with inflammation, metabolic and endocrine dysfunction. Aside from PCOS, vitamin D is crucial to fertility outcomes. It supports implantation, improves pregnancy and live birth rates and reduces the risk of miscarriage7,8,9. One study found that when vitamin D is deficient, the likelihood of live birth is reduced by 44% and ovulation is less likely to occur10.
- Dietary recommendations – a low glycemic diet that focuses on whole foods is often the best option for women with PCOS. This can help control blood glucose and address insulin resistance. Healthy fats and protein are important to include at each meal to help stabilize blood glucose. Examples include avocado, nuts and seeds, eggs, fatty cold-water fish, lean poultry, beans and legumes. Vegetables should always be a focus as a source of antioxidants and fiber. Spearmint tea has been shown to reduce androgen levels and is a great addition to dietary changes11.
Fertility challenges often come with a number of stressors including emotional, physical, relationship and financial pressure. Stress alone can lead to hormonal imbalances, insulin resistance and reduced pregnancy success. I often recommend guided meditations in my practice and utilize them during fertility acupuncture sessions. The Circle + Bloom PCOS Fertility Program includes guided meditations that are targeted towards supporting women with PCOS who are trying to conceive. Finding a meditation program that you can relate to allows you to become more in tune with your body and receive greater health benefits.
There are many other treatment options available for PCOS and its related fertility challenges. It is important to talk to a Naturopathic Doctor or healthcare professional that can support you in choosing the right testing, treatments and dosing for you.
Dr. Gina Neonakis is a licensed Naturopathic Doctor practicing in White Rock, British Columbia. She has a clinical focus in women’s health and fertility and supports women of all ages with conditions such as PCOS, endometriosis, hormonal imbalances and menopause. Gina uses an evidence-based approach and aims to treat the underlying causes of conditions, rather than suppressing them. Her goal is to empower her patients to take control of their health by educating and supporting them along their unique journey. Visit Dr. Gina’s blog at www.ginaneonakis.com.
- Javanmanesh, F., Kashanian, M., Rahimi, M., & Sheikhansari, N. (2015). A comparison between the effects of metformin andN-acetyl cysteine (NAC) on some metabolic and endocrine characteristics of women with polycystic ovary syndrome. Gynecological Endocrinology, 32(4), 285-289.
- Oner, G., & Muderris, I. I. (2011). Clinical, endocrine and metabolic effects of metformin vs N-acetyl-cysteine in women with polycystic ovary syndrome. European Journal of Obstetrics & Gynecology and Reproductive Biology, 159(1), 127-131.
- Cheraghi E, Mehranjani MS, Shariatzadeh MA, Esfahani MHN, Ebrahimi Z. N-Acetylcysteine improves oocyte and embryo quality in polycystic ovary syndrome patients undergoing intracytoplasmic sperm injection: an alternative to metformin. Reproduction, Fertility and Development 2016;28:723.
- Pundir J, Psaroudakis D, Savnur P, Bhide P, Sabatini L, Teede H, et al. Inositol treatment of anovulation in women with polycystic ovary syndrome: a meta-analysis of randomised trials. BJOG: An International Journal of Obstetrics & Gynaecology 2017;125:299–308.
- Chiu TT, Rogers MS, Law EL, Briton-Jones CM, Cheung L, Haines CJ. Follicular fluid and serum concentrations of myo-inositol in patients undergoing IVF: relationship with oocyte quality. Human Reproduction 2002;17:1591–6.
- Fruzzetti F, Perini D, Russo M, Bucci F, Gadducci A. Comparison of two insulin sensitizers, metformin and myo-inositol, in women with polycystic ovary syndrome (PCOS). Gynecological Endocrinology 2016;33:39–42.
- Ozkan S, Jindal S, Greenseid K, Shu J, Zeitlian G, Hickmon C, et al. Replete vitamin D stores predict reproductive success following in vitro fertilization. Fertility and Sterility 2010;94:1314–9.
- Li N, Wu H, Hang F, Zhang Y, Li M. Women with recurrent spontaneous abortion have decreased 25(OH) vitamin D and VDR at the fetal-maternal interface. Brazilian Journal of Medical and Biological Research 2017;50.
- Bärebring L, Bullarbo M, Glantz A, Hulthén L, Ellis J, Jagner Å, et al. Trajectory of vitamin D status during pregnancy in relation to neonatal birth size and fetal survival: a prospective cohort study. BMC Pregnancy and Childbirth 2018;18
- Pal L, Zhang H, Williams J, Santoro NF, Diamond MP, Schlaff WD, et al. Vitamin D Status Relates to Reproductive Outcome in Women With Polycystic Ovary Syndrome: Secondary Analysis of a Multicenter Randomized Controlled Trial. The Journal of Clinical Endocrinology & Metabolism 2016;101:3027–35.
- Grant, P. (2009). Spearmint herbal tea has significant anti-androgen effects in polycystic ovarian syndrome. a randomized controlled trial. Phytotherapy Research.