Insulin resistance
Polycystic ovarian syndrome (PCOS)
by Marcelle Pick, OB/GYN NP and Marcy Holmes, NP, Certified Menopause Clinician
It’s amazing how often we see women at our medical clinic with health issues that can be traced back to insulin resistance. Polycystic ovarian syndrome, or PCOS, is one such condition that we see with increasing frequency. PCOS affects about 6% of women and can occur at any age before menopause. It can often go undiagnosed for months, because its symptoms overlap with so many other women’s health concerns. PCOS itself is not a disease and no one is sure yet what causes it in the first place.
Women with PCOS have ovaries that create an abundance of follicles each month without producing an egg. PCOS can contribute to irregular periods, depression, excessive weight gain (despite diet and exercise efforts), acne, and excess facial hair. It is also the most common cause of infertility among women in the US.
PCOS is often temporary. We see it in girls going through puberty (when their ovaries are trying to set a regular menstrual pattern) and in women during the transition years of perimenopause. It usually goes hand-in-hand with insulin resistance. We find that PCOS responds extremely well to a program of natural support that restores hormonal balance, especially with the dietary changes we recommend for women with insulin resistance.
What is PCOS?
Understanding PCOS is easier if one tries to picture what goes on inside our ovaries every month. (For more on monthly cycles, please refer to our articles on menstruation, where you will also find links to information on irregular periods.)
Each month our ovaries begin to ripen a number of follicles. You may be surprised to hear that normal follicles are cysts, in that they are pockets of tissue filled with benign fluid and hormones, mostly estrogen. The amount of immature follicles changes with each cycle — but during normal times, one or two follicles grow stronger than the others and produce an egg. When we ovulate, the egg in the dominant follicle pops out and flows into the fallopian tube on its way to the uterus. This event is caused by and in turn triggers a host of hormonal secretions, including estrogen and progesterone, which work together to prepare the body to support a pregnancy if the egg is fertilized or a normal monthly period if it is not.
In PCOS, the egg is not released due to a series of alterations that take place not only in the ovaries, but in the normal hormonal pathways upstream of the ovaries as well. There is no one set scenario for how these alterations take place, and there are lots of theories and various subtypes of PCOS being proposed, but the end result is the same: no ovulation and no resulting pregnancy or period.
Polycystic ovaries
When ovaries become polycystic they create a lot of follicles that form like a pearl necklace on the ovaries. No one follicle becomes dominant and ovulation can’t occur. For the most part, these multiple ovarian cysts are not dangerous in themselves — unlike larger ovarian cysts, which can cause pain and rupture. But they do bring with them a range of uncomfortable side effects. Because a woman with PCOS doesn’t ovulate, her natural sequence of hormonal events gets interrupted, her levels of estrogen and androgens (testosterone and DHEA) remain high, and her body reacts with symptoms.
What are the symptoms of PCOS?
The most common symptoms of PCOS are irregular or absent periods, infertility, increased hair growth and unusual weight gain, even with dieting or increased exercise. Women with PCOS will often go for months without a period and then start bleeding heavily for days. This occurs when the uterine lining has gotten too thick and the body must naturally shed it. Because PCOS disrupts ovulation it can be very difficult to become pregnant.
Other signs of PCOS include acne, high blood pressure, obesity, and abnormal facial and body hair growth (due to too much testosterone). One of the less recognizable symptoms of PCOS is depression, which can be misread as a bipolar illness. While depression stems from many factors, we think it is always a good idea to consider PCOS if patients have other symptoms. In some medical practices antidepressants are prescribed which do not alleviate the underlying issues and therefore are not very helpful.
PCOS and insulin resistance
Another telltale symptom of PCOS is steady, significant weight gain — even with reduced caloric intake. Some women report that they’re gaining weight no matter what they do. It’s not unusual for patients with PCOS to tell me they’ve recently gained 60 or more pounds in less than a year, despite dieting all the time and exercise. This weight usually accumulates around their middle. Why do women with PCOS gain weight at such alarming rates? The research is showing that PCOS is strongly linked with insulin resistance.
Insulin resistance — a condition some people get by eating too many carbohydrates — leads to sustained high levels of insulin in the bloodstream. It is possible that this extra insulin hitches onto the receptors lining the ovary and stimulates cyst production. This is an issue that should be monitored because women with insulin resistance have a much higher risk of developing other serious health problems, like diabetes and heart disease. In fact, if you’re headed down the path to PCOS, what that means is that you’re now getting into the category of metabolic syndrome. This is a category you want to get out of as fast as you can, because with all the damaging inflammatory processes going on with this syndrome there is potential for serious problems down the road.
Another interesting consideration for some is that while many people think of PCOS as a condition that only affects women who are overweight, we do from time to time see women who are thin who have insulin resistance and PCOS. Though not often, at our clinic we do see from time to time see thin women with insulin resistance and PCOS.
On the bright side, women with insulin resistance and PCOS respond very well to modifications in their diet, adding nutritional support in the form of soy and other functional foods, multivitamins, minerals and omega-3’s, and beginning an exercise program. We’ve found that our patients often get normal periods as their insulin levels normalize. This is something that’s always treatable and easily treatable, which for us as practitioners is very exciting!
Should I see a doctor if I think I have PCOS?
If any of these symptoms describe what you’ve been feeling, it’s important to see your healthcare practitioner. If I suspect PCOS in a woman I will do a complete evaluation, including checking for insulin resistance. This work-up includes a physical examination, a fasting lipid profile, a glucose test, hormone levels, and an insulin test (before and two hours after a high-carbohydrate meal). A blood sample is very informative for testing elevated thyroid and prolactin levels. If these tests come up positive, I also look for an altered FSH-to-LH ratio and increased levels of androgens. Occasionally I will suggest a pelvic ultrasound. It can be possible to see the pearl-necklace pattern of cysts on some women’s ovaries.
If there is any abdominal pain or pressure around the ovaries, an evaluation is certainly necessary. In most cases a woman will be monitored on a regular basis to make sure her cysts are not at risk for rupture.
If a patient has been trying to get pregnant for more than a year, I usually refer her to a fertility specialist, especially if she is over the age of 35. Ovulation stimulants, like Clomid, can be helpful for many would-be moms who have PCOS. When a non-menopausal woman skips a period for more than four months, pregnancy should be considered. Having regular menstrual periods is important to prevent osteoporosis and maintain the protective effects of estrogen elsewhere in the body.
Occasionally a woman with PCOS will simply not get her period. If she is not pregnant, I advise stimulating a period after four months with the use of micronized progesterone (a bioidentical hormone). Other practitioners will sometimes suggest synthetic progestins such as Provera or Aygestin. This protects the lining of the uterus from becoming too thick or unusual.
What is the treatment for polycystic ovarian syndrome?
Traditionally, doctors have overlooked PCOS unless it is diagnosed relative to infertility or irregular bleeding. If diagnosed, it was and often still is commonly treated with birth control pills. The Pill lessens the symptoms of PCOS by short-circuiting ovulation and giving the ovaries a rest from follicle production. This is always an option for women looking to avoid pregnancy. Testosterone levels will go down on the Pill, and it is good for regulating cycles but it won’t address the basic issue of insulin resistance. Some doctors are now prescribing a diabetes drug called metformin (Glucophage), for blood sugar control, but in my experience if a woman with PCOS doesn’t attend to some of her lifestyle choices — such as following a low glycemic-load diet — her ovaries become polycystic again when she goes off either type of pill. This is particularly irksome for women trying to get pregnant.
At our medical practice, we treat PCOS with a combination approach, whether it is a chronic problem in younger women or a temporary condition of perimenopause. We’ve helped countless women reduce their polycystic ovaries through nutritional supplements, gentle endocrine support, enriched nutrition and regular exercise. This support is available at-home through our Personal Program. Our nurse–educators can explain all your options, including phytotherapy to gently reset your progesterone, testosterone, and estrogen pathways; bioidentical progesterone to jumpstart regular monthly periods; extra omega-3’s and functional foods to reduce proinflammatory mediators that arise from extra weight and insulin resistance; and other natural ways to help your body detoxify hormone metabolites and recover balance. This personalized combination approach is an effective way to bring the body back into hormonal balance.
If you have PCOS or think you do, I hope that you will take heart in realizing there are many things you can do to alleviate your symptoms naturally, without drugs. Like any condition related to hormone imbalance, taking the right steps to improve your lifestyle and nutrition will do wonders to restore your well-deserved good health.
Our Personal Program is a great place to start
The Personal Program promotes natural hormonal balance with nutritional supplements, our exclusive endocrine support formula, dietary and lifestyle guidance, and optional phone consultations with our Nurse–Educators. It is a convenient, at-home version of what we recommend to all our patients at the clinic.
We’re always happy to welcome new patients to our medical clinic in Yarmouth, Maine, for those who can make the trip. Click here for information about making an appointment.
Related to this article:
References & further reading on polycystic ovarian syndrome
Original Publication Date: 09/28/2004
Last Modified: 05/08/2008
Principal Authors: Marcelle Pick, OB/GYN NP
& Marcy Holmes, NP, Certified Menopause Clinician