In this latest series, I am exploring everything to do with fertility. So far we have looked at how to improve your fertility, the importance of folic acid and male fertility. If you have missed any of these articles you can read the following:
- Sowing a Seed: Improving Fertility with Seeds and Oil
- Fertility & Folic Acid – Why taking folic acid may not be enough
- Wanting To Get Pregnant? Don’t Forget About Sperm Health
This week I want to explore polycystic ovarian syndrome (or PCOS), a common endocrine disorder that affects many women. PCOS is caused by cysts on the ovaries that secrete increased levels of testosterone (also called androgens) and estrogen which causes a hormonal imbalance. The cysts themselves are not dangerous but the hormone imbalance can prevent ovulation.
What Is Ovulation?
Ovulation is when the ovary releases a mature egg (follicle) full of DNA and ready to meet a sperm for fertilization. Ovulation is controlled by a hormonal feedback loop from the pituitary gland in the brain to the ovary. Circulating levels of estrogen and progesterone regulate this feedback loop and tell the pituitary gland to increase follicle stimulating hormone (or FSH) for follicle development and increase luteinizing hormone (LH) to eject the follicle from the ovary. If estrogen and progesterone levels are out of balance then this affects the feedback loop and ovulation does not occur. If ovulation has not occurred then a women will not get her period (which would normally happen 10 days to 2 weeks post-ovulation) – this is called an irregular menstrual cycle.
If we don’t ovulate then we don’t release a follicle in order to get pregnant. In addition to playing a role in ovulation the hormone imbalance caused by PCOS can affect weight, mood, hair growth, can cause acne and increase risk factors for diabetes and heart disease.
What Causes PCOS?
There are a number of factors that can contribute to the development of PCOS:
- Weight gain
- Poor diet
- Lack of exercise
Research has shown that women with PCOS have low-grade inflammation which occurs when the body’s white blood cells produce substances to fight infection. This type of low-grade inflammation stimulates polycystic ovaries to produce androgens (testosterone and estrogen).
Signs and Symptoms of PCOS
Signs and symptoms of PCOS often begin soon after a woman first begins having her periods although, in some cases, it can develop later on in the reproductive years.
As a primary care physician I find this condition is often overlooked as a diagnosis in women. Many doctors will dismiss the diagnosis if the ovaries don’t have a significant number of cysts on them, however, PCOS is a spectrum and women may have mild, moderate or severe PCOS depending on where they are on that spectrum. Here is a list of the signs and symptoms that women with PCOS can experience:
- Irregular periods or no period at all
- Heavy periods
- Excessive facial or body hair
- Pelvic pain
- Weight gain
- Inability to lose weight
- Type 2 diabetes
- Sleep apnea
- Heart disease
- Mood swings
- Endometrial cancer
If a woman has fewer than eight menstrual cycles per year, there is an 80% potential chance she has PCOS. If you are experiencing any of the above symptoms, your doctor may want to investigate further to see whether you have PCOS. These investigations will include bloodwork and an ultrasound. The following labs are what I use when I am screening for PCOS or suspect a patient has it.
- Estrogen levels
Blood is not the best marker for checking estrogen levels but it can be a guide to see how hormone levels are running. Excessively high levels of estrogen point to an estrogen dominance which is an indicator of PCOS.
- Testosterone levels
I find this to be a better marker for PCOS than estrogen. Over the years, having looked at thousands of female testosterone levels, most women run between 3-20ng/dl. When I see female lab values of 40ng/dl and above, I start looking for other indicators of PCOS such as acne, facial hair growth and thinning of the hair on the scalp which are all caused by elevated testosterone.
- Follicle Stimulating Hormone (FSH) & Luteinizing Hormone (LH)
FSH & LH are both produced by the pituitary gland. They are released as part of a feedback system from the pituitary gland to the ovaries. The role of FSH is to stimulate follicle development in the ovary. FSH is secreted in response to changes in circulating levels of estrogen in the blood. As the ovary finishes the development of its monthly follicle, increased levels of estrogen and progesterone circulating in the body cause the pituitary gland to release LH in order to trigger the release of an ovarian follicle from the ovary. LH can be elevated in PCOS so checking LH to FSH ratio can confirm diagnosis.
- Hemaglobin A1C (HbA1c)
HbA1c is the part of the red blood cell that carries around a glucose molecule. The higher the level of glucose circulating in the blood, the more hemoglobin A1C there is. Elevated HbA1c levels are primarily used to diagnose diabetes but they are also a great marker for evaluating PCOS. A normal HbA1c level would be 4-5.6%, 5.7 % to 6.4% indicates pre-diabetes and an HbA1c above 6.5% is considered diabetes. The life span of a red blood cell is 3 months, so this test is a reflection of your sugar metabolism over the last 3 months.
- Fasting insulin
Insulin is produced by the pancreas and is responsible for shuttling glucose out of the blood and into the cells. PCOS is correlated with elevated levels of insulin. Excess insulin increases androgen production which can interfere with the ovaries’ ability to ovulate. If you have insulin resistance, your ability to use insulin effectively is impaired, and your pancreas has to secrete more insulin to make glucose available to cells which can exacerbate the problem.
- Fasting glucose, cholesterol & triglycerides
Glucose levels in the blood will be elevated in PCOS. When glucose is not metabolized, or burned up, the body will convert it to fat (cholesterol & triglycerides). Checking fat levels in the blood gives an indication of how well the body is handling glucose in the diet.
- C-reactive protein
C-reactive protein measures inflammation in the body; if it is elevated it points to underlying inflammation. This measurement is primarily used to evaluate one’s risk factor for heart disease, however inflammation present in the body can cause damage to any tissue. There is an inflammatory aspect to PCOS and identifying and treating inflammation is part of a PCOS treatment plan.
An ultrasound uses sound waves to show an image of what’s going on inside the body. When an ultrasound is done to look for signs of PCOS, the technician examines the ovaries for follicles and cysts. PCOS can appear as multiple small or large cysts on the outside of the ovary, or as a small, white string of “rosary beads” inside the ovary. However I do want to point out that the ultrasound report is only as good as the technician reporting the finding. While cysts on the outside of the ovary are fairly apparent, the “rosary bead” pattern of cysts inside the ovary is not as commonly observed by the ultrasound technician and therefore may not be documented.
A positive ultrasound in addition to elevated testosterone levels and absence of period are considered evidence of PCOS. However, PCOS is a progressive condition and, in the early stages, you may not observe as many signs and symptoms so, just because someone does not have all the criteria for PCOS it does not mean they may not go on to develop those markers over the next few years. That is why, when I suspect PCOS, I always educate my patients on it and suggest diet and lifestyle changes that can help prevent any further progression of the condition.
How to Treat PCOS
PCOS is fairly common and many women with PCOS go on to have healthy babies, the key is getting the treatment right to ensure a good hormonal balance.
And, even if you don’t have an official diagnosis the following courses of action can improve your hormonal balance and increase your chances of getting pregnant.
- Diet – addressing weight loss and treating insulin resistance
Following a low glycemic or low carbohydrate diet is needed to lose weight and reduce insulin resistance. There are many popular low glycemic diets such as Atkins, South Beach and Paleo style diets. The key is to eat no more than 25 grams of carbohydrates a day for 2 weeks to get to get to the point where the liver has burnt up all of its sugar stores and is starting to using fat as fuel – this is called ‘ketosis’. Once Ketosis has occurred then carbohydrate consumption can be increased to between 50 and 100gms a day until your weight goals are achieved. For some people, a 10lb weight loss can be enough to get their menstrual cycles flowing again.
- Estrogen Metabolism
There are supplements you can take to improve estrogen break down and excretion by the liver. This helps to reduce your circulating level of estrogen and bring hormonal balance. Long term elevated levels of estrogen increase risk of both uterine and breast cancers. Products that contain DIM or Indole 3-carbinol are used to improve estrogen metabolism. I use a product called Bio-cleanse to help with the liver’s metabolism of hormones. Click here to buy this product from my online pharmacy.
Taking progesterone on days 12- 24 of your menstrual cycle can help with regulation of your period. Progesterone is dominant during the second half of your menstrual cycle from ovulation until you start bleeding again at your next period. It is the drop in progesterone that begins the start of the next menstrual cycle.
Metformin is a pharmaceutical drug used to treat diabetes that can also help increase fertility in women with PCOS. Many women will experience regular menstrual cycles after taking this medicine.
Regular exercise is important both for weight control and for reducing insulin resistance.
- Quit Smoking
The increased toxins from smoking contribute to poor hormone metabolism so giving up cigarettes can help restore your hormone balance.
- Anti-Inflammatory Diet
By reducing inflammation in the body you can reduce the production of androgens (testosterone). Eating a diet rich in fruits and vegetables, low in grains, sugar and alcohol can help reduce your inflammation. Testing for food sensitivities can also play a pivotal role in reducing your inflammation by telling us which foods are increasing inflammation in your body.
- Nut And Seed Oil Rotation
Omega 3 fatty acids, specifically DHA and EPA, are helpful in managing the symptoms of PCOS. Both EPA and DHA are found in fish oil so taking between 500-1000 mg each of DHA and EPA is recommended to help with symptoms of PCOS.
You can increase your intake of Omega 3 fats and balance the estrogen and progesterone stages of your menstrual cycle by following my simple nut and seed oil rotation.
Polycystic ovarian disease is very common and many women go undiagnosed for years. If you have a history of irregular cycles, acne, facial hair growth and weight concerns then ask your doctor about being tested for PCOS.
Aside from improving your fertility, early detection of PCOS can also help prevent the long-term development of diabetes and heart disease that can occur over the years.
Please schedule an appointment to discuss your health concerns or to find out about my fertility treatment options. Treating fertility really does mean addressing the whole body and PCOS is an example of how hormones are interconnected throughout the body. Join me next week when I will discuss the role that thyroid hormone plays in fertility.