Polycystic Ovarian Syndrome (PCOS):
What you need to know

Image Credit: FabianMontano/EnvatoElements.com

By Kim Ross, DCN & Mona Fahoum, ND
Reviewed by Deanna Minich, Ph.D.

September 20, 2023

What you need to know about PCOS

Polycystic Ovarian Syndrome, or PCOS, is considered one of women's most common endocrine and metabolic issues. It is estimated that up to 22% of women from all ethnicities and backgrounds in their reproductive years contend with this disruptor of hormones and metabolism, depending on the diagnostic criteria used (1–3). An even more significant issue is the finding that many women are left undiagnosed for an average of two years and see multiple health professionals before a diagnosis is made (3–5).  

What makes this condition so difficult to diagnose by medical providers?

First, the name is misleading and continues to create confusion in the medical community (3). While increases in the number of follicles (cysts) on the ovaries, often referred to as the “string of pearls,” can be seen in PCOS, this alone is not sufficient for a diagnosis of the condition (2,6). Further, some patients with PCOS do not have to have any cysts on ultrasound but may still be diagnosed with the condition. How is this possible? After years of varying viewpoints in the medical community, the criteria for diagnosing PCOS have evolved as a deeper understanding of the condition is realized—though this remains an area of conversation for clinicians and researchers.

According to the most recent diagnostic criteria, known as the modified Rotterdam criteria for diagnosing PCOS, two of the following are present*: (7)

1. High androgens or hyperandrogenism symptoms
2. Menstrual cycle irregularities
3. Changes in ovary 

*This information is for educational purposes only. Diagnoses are provided by your healthcare provider. Descriptions are provided in Table 1.

With that said, you may also see the four types of PCOS (Table 1) mentioned, which were criteria established in 2012 and it continues to serve as a convenient way to approach research and clinical care (8–10).

Table 1: Four Phenotypes of PCOS

Abbreviations: DHEA:dehyroediandrosterone; >: greater than; <: less than
*Phenotypes have been reported as A-D and 1-4 but contain the same criteria (8,9)
** Ovarian changes include: Polycystic appearance on ultrasound (20 or more follicles per ovary or 10 cm3 or greater ovarian volume)

It is worth noting that some websites classify the four types of PCOS as “functional PCOS types” described as:

• Insulin-resistant PCOS
• Inflammatory PCOS
• Post-Pill PCOS
• Adrenal PCOS

It is important to note that functional PCOS types do not fully meet the medical definition or criteria used for a medical diagnosis by a qualified healthcare provider. Additionally, scientific evidence does not support these particular classifications. Instead, some clinicians may find this an easy, convenient way to think about addressing the root cause of a woman’s concerns as it relates to PCOS.  

Unsure of your type? No worries!

Regardless of the “type” of PCOS the foundational diet, supplements, exercise, and lifestyle factors that regulate insulin and glucose levels, lower inflammation, balance hormones, and reduce stress are the same.

Common Signs and Symptoms

Beyond the diagnostics, women with PCOS can experience a range of signs and symptoms, including, but not limited to: (10)

• Acanthosis nigricans (dark, thick velvety skin in body folds/creases such as the neck or armpits)
• Acne
• Androgenic alopecia (thinning and diffuse hair loss, sometimes called “male pattern baldness”)
• Bowel symptoms that mimic irritable bowel syndrome (IBS)
• Decrease in follicle-stimulating hormone (FSH) levels
• Hirsutism (excessive body hair)
• Increase in androgen hormones (testosterone, DHEA)
• Increase in luteinizing hormone (LH) levels
• Infertility
• Insulin resistance
• Irregular menstrual cycles
• Obesity
• Pelvic pain
• Unexplained weight gain/inability to lose weight
• Virilism (development of masculine characteristics)

What can you do?

First, if you have any of the above-mentioned concerns, you should visit your medical practitioner for an evaluation and to learn more about the best options of care for you.

How you manage your diet, exercise, stress, and other lifestyle factors may directly impact your hormone health and outcomes of PCOS.

Hormones

There are two main androgenic hormones that are included in the diagnostic criteria for PCOS (testosterone and DHEA) but all reproductive hormones are important to women’s health.

• Testosterone: Levels may be elevated beyond what is normal for women, especially as compared to estrogen levels.

• DHEA: Levels may be elevated beyond what is normal for women.

The following hormones are not part of the diagnostic criteria for PCOS, though an imbalance may contribute to some symptoms.

• Luteinizing hormone (LH): Levels may be increased.
• Follicle Stimulating Hormone (FSH): Levels may be decreased.
• Estrogen: Levels may be normal, decreased, or elevated.
• Progesterone: Levels may be normal or decreased.

There are a number of steps you can take to improve your hormone status naturally including the following which will be covered in detail further in this blog:

1. Improving diet and overall nutrition status
2. Increasing exercise and movement
3. Practicing stress management
4. Enhancing select lifestyle factors

In addition, supplements can provide support while you are working on modifying diet, exercise, stress, and other lifestyle factors.

For example, licorice root and saw palmetto have been shown to be beneficial in supporting better breakdown of testosterone in the system, which may help with excess hair growth and acne (11,12). Red clover and chaste berry may help increase progesterone levels (13).  

Choosing something that addresses the body’s production of hormones to aid in restoring balance is ideal. Hormone balancing begins at the brain in the hypothalamus, cascading down through the pituitary, thyroid, adrenal glands, and eventually the ovaries. This process is referred to as the hypothalamus-pituitary-thyroid-adrenal-ovarian (HPTAO) axis.

Lepidium peruvianum, commonly known as maca, has been shown to improve estrogen and progesterone production by nourishing the body’s HPTAO axis rather than introducing any hormones to the body (14–17). But not just any maca will do. Choosing the right maca is especially important for women with PCOS. Some types of maca can increase androgen activity, potentially making PCOS and its symptoms worse. One case report showed increased testosterone levels in a woman after taking generic maca supplements (18).

There are many options to consider when selecting the best supplements for your needs. We encourage you to speak to your healthcare providers to determine what will provide you with the best support.

Diet and Nutrition

There isn’t one dietary pattern that all women should follow. Research demonstrates benefits to many food plans, such as the Mediterranean, Paleo, DASH, and Ketogenic diets (19–22). The best food plan is one you can comply with and should be personalized to your likes and lifestyle!

Even though one’s diet needs to be personalized, here are some general nutrition guidelines that may benefit PCOS, regardless of the food plan you may follow.

Drink Water

Proper hydration aids in delivering nutrients, regulates body temperature, improves mood and concentration, increases/maintains energy, lubricants joints, and supports healthy detoxification. It is also critical to support regular bowel movements, urination, and sweating – our three routes of eliminating waste from our bodies. Water intake may need to be adjusted based on physical activity and sauna use, to name a few.

Do you find water boring? Jazz it up! Consider adding fruits like oranges, lemons, limes, and grapefruit, herbs like mint, cilantro, and rosemary, or vegetables like cucumbers. Don’t be afraid to get creative and combine some of these as well, such as cucumber & mint or grapefruit & rosemary. Additionally, you may consider mineralizing your water. One study demonstrated that mineralized water increased hydration indicators by 10% and was effective in stabilizing pH (23).

Support gut health

The general dietary suggestions made will inherently assist in optimizing gut health. However, there may be some additional options to consider.

Seek guidance from a trained professional for assistance with creating a nutrition plan that will work for your health concerns and lifestyle.

Exercise and Movement

Exercise and movement aim to gain muscle mass that improves metabolism and cardiovascular stamina for heart health. It is best to use a combination of aerobic and resistance exercises to improve PCOS. What is important is getting the heart rate up and making your muscles work.

Some tips to help you move more:

• Do what you enjoy! For some, it may mean the gym and hitting the elliptical and weights. For others, it can be the pool, and still others, the dancefloor. Find a combination of activities that you enjoy.
• Add some resistance activities – consider squats, lunges, push-ups, resistance bands and/or light weights to give your large muscle groups some additional attention.
• The pool is a great place to combine aerobic with resistance. The water provides a natural resistance as you swim.
• Find a buddy or group to work out with or to participate in classes or activities. Think about things like a hiking group, dance class, yoga/pilates class, soccer team, golf, tennis, or others. Find something fun that happens to be exercise.
• Schedule a time with yourself for exercise…and then keep your appointment! Can you get up 30 minutes earlier? Is there a gym on the way to/from work to make it easier to stick with?
  
  

Seek guidance from a trained professional for assistance with creating the ideal exercise routine.

With their support, you can ensure exercise meets your likes, time schedule, and addresses any health or joint concerns (i.e., weak back or knees).

Stress Management

Chronic stress, whether emotional or physical, is known to affect hormone balance.

You can work to reduce stress and its effects by:

• Coloring, journaling, or completing puzzles
• Engaging in meditation, guided imagery, prayer, or breathwork
• Getting a massage
• Practicing yoga
• Reading
• Sippng on some tea and do nothing. Chamomile and spearmint tea have been shown to help reduce testosterone levels (13).
• Soaking in a bath with bath salts and calming essential oils, like lavender.
• Taking intentional “pauses”. This can be a time for doing something creative or just simply ‘being’.
• Watching a comedy

Just like exercise, find something you enjoy doing and make time for it.

Lifestyle & Environment

Modifying lifestyle factors can also be helpful for hormonal balance.

Support quality sleep

It is twice as common for women with PCOS to have sleep difficulties (28). Ensure you practice good sleep hygiene and get evaluated for sleep apnea if appropriate. Aim for 7-9 hours of sleep nightly by establishing a regular bedtime, turning off electronics/screens at least 1 hour before bed, and calming yourself with some stress management techniques listed above.

When indicated, you may find benefits from calming herbs such as chamomile, lavender, valerian, or lemon balm (29,30). Further, L-theanine, found in green tea, can help promote relaxation and sleep (31). And perhaps one of the most known supplements to support sleep is melatonin (32).

Be sure to check with your healthcare provider before starting any sleep support supplements.

Reduce exposure to endocrine-disrupting plastics and chemicals

Increasing research shows that constant exposure to chemicals interferes with normal hormone function and PCOS (33). Plastics, in particular, act like estrogens in the body, further throwing hormones out of balance in a PCOS patient.  

• Buy BPA-free water bottles and containers.
• Drink tea or coffee from a reusable mug, especially when on the go!
• Avoid microwaving food in plastic containers or coverings.
• Avoid fragrances wherever possible (perfumes, scented products, etc.).These are known disruptors of the endocrine system.
  

Review the Environmental Working Group’s Dirty Dozen Endocrine Disruptors for more information.

Following an anti-inflammatory dietary plan, as described above, includes foods that support the elimination of toxins from the body. However, there are specific foods and supplements that may provide additional support such as milk thistle, dandelion greens, spirulina, and alfalfa (34,35).

Quit smoking

Smoking interferes with proper estrogen production and clearance. It has been associated with worsening metabolic profiles and insulin resistance in women with PCOS (36).

Conclusion
There are many dietary and lifestyle factors that may help manage PCOS. Our goal is to help you improve hormonal health through diet and lifestyle choices and using supplementation as needed.

Working with a health professional who can customize a plan to meet your individualized needs is best.

Supplement Disclaimer:
These statements have not been evaluated by the FDA. These products are not intended to diagnose, treat, cure, or prevent any disease.

Medical Disclaimer:
This blog is for educational purposes only and is not intended to diagnose, treat, or prescribe. All material provided does not substitute medical, psychological, or nutritional advice and/or services. The company does not accept responsibility for any action taken based on the contents of this blog.

For more information our team of doctors, who specialize in women’s hormone health and PCOS, created a free PCOS Guide you can download here

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