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PCOS 101: Everything You Need to Know About Polycystic Ovarian Syndrome

I’ve been where you are right now… Maybe your doctor just told you, “You have PCOS.” Maybe you’re questioning it yourself… Googling for answers.

Or maybe - and this might be the most frustrating situation of all - you’ve been told for YEARS you had PCOS, only to be told now, you somehow, suddenly don’t.

The fear, overwhelm, frustration, uncertainty - I get it! (I have PCOS, myself.)

Nothing about PCOS is straightforward. (Even the name doesn’t make sense!)

So let me hold your hand for a minute - today I want to explain everything you need to know about PCOS, start to finish. 

What Is PCOS?

PCOS stands for Polycystic Ovarian Syndrome - and it’s an endocrine (AKA hormonal) disorder that affects women of reproductive age. 

PCOS is the most common hormone dysfunction among women and affects 10-20% of all women of reproductive age. 

(That means if you get a group of 10 of your friends together, it’s likely 1-2 of you will have PCOS!)

And despite the name, PCOS really has nothing to do with cysts on your ovaries. Instead, PCOS is a condition marked by elevated levels of androgens (commonly called male hormones.) This is often testosterone, but can include other androgens. 

People with PCOS often also have elevated luteinizing hormone (LH), and prolactin and lower follicle stimulating hormone (FSH).

And while your doctor might not make a big deal out of it, the truth is that PCOS is a lifelong disease with big medical and emotional impacts, and potentially the additional burden of obesity.

What Are The Symptoms of PCOS?

Symptoms of PCOS include:

• ­Hirsutism
• Male pattern hair loss or thinning
• Acne
• ­Oligo or amenorrhea (chronic anovulation)
• ­Obesity
• Sub/­ Infertility
• Low libido and sexual problems
• Skin tags or darkened skin in the folds (acanthosis nigricans)
• GI problems (IBS, leaky gut)
• Arthritis and tendonitis
• Depression, anxiety, stress, eating disorders, and body dysmorphia 
• Increased vaginal infections
• Sleep dysfunction
• Increase in certain cancers (uterine and breast)
• Increased rates of other gyn conditions, like fibroids, endometriosis

PCOS can also lead to:

• Pregnancy complications
• High blood pressure
• Diabetes
• Dyslipidemia
• Fatty liver
• Higher risk of cardiovascular disease

PCOS can present very differently in different women, and there are at least 4 different types (more on that to come). 

One big misconception? That all people with PCOS are overweight. Although overweight/obesity is common in PCOS, it is not a symptom for all people with the condition. 

Another misconception is that PCOS causes painful periods or pain. That’s not true either. If you have pain or painful periods, it is likely caused by something else (though it’s possible you have PCOS, too - it just isn’t the cause of the pain!)

How Do I Know If I Have PCOS?

How PCOS is diagnosed has changed over the years, which is part of why there is so much confusion around who does and doesn’t have PCOS. If you’ve been told you did have PCOS, but don’t now - the changes in diagnostic criteria explain why. 

In the past, PCOS was diagnosed primarily based on missing or irregular periods and the presence of multiple cysts on the ovaries, as seen via ultrasound.

But now we know that there are many reasons cysts can appear on the ovaries - and sometimes, those cysts are entirely normal and not indicative of any disease state. 

That’s why, today, PCOS is diagnosed based on updated guidelines from 2018 for missing or irregular periods AND androgen excess, which is determined as:

1) high androgens (male hormones) measurable on a blood test, 

and/or 2) significant facial hair or jawline acne.

PLUS other reasons for androgen excess have been ruled out.

Ultrasound is no longer required to diagnose PCOS, though many practitioners still do perform one. 

Even if you are missing periods, or have them irregularly, or if you had an ultrasound that featured cysts on your ovaries, if you do not have androgen excess as defined by labs or symptoms mentioned above, then it’s not considered PCOS. (Missing your period, but no androgen excess? There are lots of other reasons for missing periods. Read more here.)

Other signs of PCOS include the following, but these all are not always present, even with PCOS:

• Bilateral polycystic ovaries 
• ­Elevated LH and LH to FSH ratio 
• ­Oligoovulation (irregular or infrequent ovulation)
• Elevated free testosterone and DHEAS 
• ­Glucose intolerance and elevated insulin 

When Hormone Levels Are “Normal” But You Still Have PCOS Symptoms

If you have key symptoms of androgen excess - such as severe jawline acne and facial hair growth - but your lab tests are normal, don’t rule PCOS out. 

Some women are extremely sensitive to even “normal” amounts of androgens. This means that even with normal levels, they may have key symptoms like jawline acne and facial hair growth. That’s why the guidelines state that PCOS diagnosis can be based on either elevated androgen levels on a blood test or symptoms of high androgens. 

But, there are also other conditions aside from PCOS that can cause the symptoms of androgen excess, including:

• Congenital adrenal hyperplasia (an inherited condition that impacts the adrenal glands and sex hormones)
• High prolactin secretion
• History of using an oral contraceptive pills that contain progestins, which behave more like testosterone than progesterone in the body

Is It PCOS… Or Something Else?

Other conditions can sometimes be mistaken for the more-common PCOS. These include:

#1 Non-Classic Adrenal Hyperplasia (NCAH)

This condition is similar to congenital adrenal hyperplasia, but comes on later in life (usually around the time of puberty) and is not as severe. For women, symptoms include delayed first period (menarche), male-pattern hair growth and loss, and infertility. It is hard to tell the difference between PCOS and NCAH, but if a person presents with PCOS symptoms and is not insulin resistant, it could be NCAH - though some people with NCAH do have insulin resistance. NCAH is more rare than PCOS. The only way to distinguish PCOS from NCAH with certainty is by measuring 17-hydroxyprogesterone levels. 

#2 Functional Hypothalamic Amenorrhea

This is the loss of normal menstrual cycles due to overexercise/undereating, and it often occurs in both normal and underweight women. It can be really difficult to distinguish a woman with FHA from a woman with PCOS who is lean. Tell-tale signs that it is FHA include low to normal basal FSH and LH levels and low estrogen (vs. elevated serum LH levels and low to normal FSH levels in women with PCOS). Women with FHA don’t usually have the severe jawline acne or male-pattern hair growth seen in PCOS. On an ultrasound, both women with PCOS and FHA may have cysts, but the ovaries and uterus of a woman with FHA are small or normal, whereas a woman with PCOS typically has increased ovary size. To make it a little more complicated… it is possible to have both PCOS and FHA simultaneously. 

What Causes PCOS?

The exact cause of PCOS is not known, but it is likely a combination of genetic predisposition and environmental effects. Some known risk factors are:

• Mother had gestational diabetes (it’s thought that the exposure to higher levels of insulin levels in utero could lead to PCOS in adulthood).
• Exposure to endocrine disrupting chemicals in utero or in life. So far the focus has been of BPA.
• Diabetes or metabolic syndrome in first degree relatives
• Gut inflammation, such as IBS, SIBO, or leaky gut (because they cause chronic inflammation)
• Higher levels of oxidative stress, beginning in utero and continuing through life
• Vegetarian diet, which may contribute to low levels of zinc and 
• Autoimmunity
• Hypothyroidism

It’s also suspected that a genetic mutation of the CYP17 enzyme, which is responsible for forming androgens from DHEA-S, could play a role. 

Beyond these risk factors, it isn’t known exactly why some women develop PCOS and others don’t.

While what starts the initial process of PCOS remains mostly unknown, we do know what happens in the body that leads to PCOS. It’s a hormonal cascade that starts with hypothalamic gonadotropin-releasing hormone (GnRH). 

First up, in a woman without PCOS, here’s what happens: hypothalamic gonadotropin-releasing hormone (GnRH), stimulates the release of LH - luteinizing hormone. The LH tells special cells in the ovaries called theca cells to convert cholesterol (a type of fatty acid in the body) into two androgens: testosterone and androstenedione. The androgens then move into the granulosa cells, where the hormone FSH (follicle stimulating hormone) converts them into estrogen via a process called aromatization. 

But in a woman with PCOS, the process gets stalled out before the androgens can be converted into estrogen. Here’s what happens...

Women with PCOS have increased pulsatile GnRH release, which results in higher levels of LH and lower levels of FSH in most individuals. These higher LH levels cause increased androgen production by follicular theca cells. That means a woman with PCOS has more androgens to convert to estrogen to start - plus a lower FSH level, which is the hormone needed to convert the androgens to estrogen.

All those extra androgens in the ovaries stop the normal growth and maturation of follicles, and prevent ovulation. As a result, the ovaries wind up with lots of small, antral follicles that become cysts on the ovaries. This enlarges the ovaries and can also create an elevated serum estrogen level. 

But that’s not all! In addition, the cells of people with PCOS respond to normal levels of  the “blood sugar hormone” insulin by making increased amounts of testosterone. In a woman without PCOS, these levels of insulin would not result in excess testosterone. 

This is intensified by the fact that women with PCOS also are far more likely than people without PCOS to have insulin resistance and elevated insulin levels. 

PCOS and Insulin Resistance

PCOS and insulin resistance have a complex relationship: insulin resistance is both a symptom and a potential cause of PCOS. 

But before we dig any further, let’s do a quick refresher on what insulin and insulin resistance are. 

Insulin is a hormone secreted by the pancreas in response to blood sugar. When you eat food, it is broken down and absorbed into the bloodstream in the small intestine. This causes a rise in blood sugar. In response to this rise in blood sugar, the body pumps out insulin from the pancreas. The insulin helps shuttle the sugar out of the bloodstream and into the cells, where it can be used as energy. 

Insulin resistance is one way this system can break down. Essentially, the pancreas continues making insulin, but the body stops listening. That can lead to both high levels of insulin (because the pancreas keeps making more) AND high blood sugar levels, since the insulin isn’t doing its job of moving the sugar out of the bloodstream and into the cells. 

Insulin resistance is often the first step on the road to developing Type 2 diabetes and gaining weight, which is harder to lose. 

Insulin resistance is very common in PCOS: even in non-obese women with PCOS are far more likely than other women of the same weight without PCOS to wind up with insulin resistance.

And while we don’t know for sure if the PCOS causes the insulin resistance… or the insulin resistance causes the PCOS… what we do know is that high levels of insulin stimulate the ovaries to make more testosterone. At the same time, high testosterone levels in women lead to insulin resistance and weight gain.

Being overweight with PCOS only intensifies the metabolic problems. Excess fat cells lead to fatty acids spilling into the bloodstream. Combined with the low antioxidant and high oxidative stress seen in PCOS, this leads to increased oxidation of the fats, which damages tissues. This creates yet another cycle where oxidative stress increases testosterone production, which only increases insulin resistance. Once this cycle is set in motion, it’s really difficult to stop. 

PCOS is also inflammatory, and this inflammation further increases insulin resistance and abdominal visceral fat. The inflammation also promotes abnormal adipose function with inappropriate adipokine release. Adipokines include the “hunger and fullness” hormones leptin and ghrelin. 

PCOS and The Microbiome

PCOS doesn’t just affect your hormones, however. It can also have major, negative consequences for the microbiome.

The microbiome is the collective name for all the bacteria that live in your gut and perform vital roles in digestion, metabolism, hormone production, and communication between body systems. 

Stool testing showed the microbiome of people with PCOS was less diverse and had an altered composition compared to healthy controls.

The dysbiosis in the microbiome that PCOS can cause promotes even more inflammation, as well as allergies and autoimmunity. Research has shown that women with PCOS (both those who were lean and those who were overweight) had significantly higher LPS levels, a marker of inflammation and leaky gut, compared to healthy controls.

And, in another example of the way PCOS symptoms can be self-perpetuating, a dysbiotic microbiome as a result of PCOS could contribute to further weight gain and insulin resistance, further fueling excess androgens. Studies have shown that changes in gut microbiome trigger mechanisms that promote obesity, Type 2 diabetes, and metabolic syndrome. And, it’s known that people with Type 2 diabetes also have an altered microbiome. 

Both obesity and dysbiosis, two common results of PCOS, directly increase gut permeability (leaky gut), which promotes insulin resistance, which drives further testosterone production in the ovaries, creating PCOS, which impairs ovulation and promotes further androgen dominance. 

Bottom line: if you’re struggling with weight loss and obesity, and have PCOS, a dysbiotic microbiome could be a reason why. 

What Happens If PCOS Is Ignored

For most people with PCOS, symptoms like unwanted facial hair and jawline acne are enough to make them want to seek treatment. PCOS can really impact quality of life. 

But even if PCOS symptoms aren’t bothersome, leaving this condition untreated long-term has serious consequences.

Of course, PCOS affects fertility: it is more difficult or impossible for those with PCOS to become pregnant due to their irregular/absent ovulation. 

However, even if you never want to become pregnant, PCOS does far more than affect fertility.

The high androgens produced in the ovaries lead to insulin resistance and inhibited ovulation. The insulin resistance puts you at risk for Type 2 diabetes and weight gain. In addition, even if insulin resistance isn’t a feature of your PCOS, the high testosterone levels seen in PCOS also increase the risk of Type 2 diabetes.

The inhibited ovulation leads to low levels of progesterone (because progesterone rises when ovulation occurs). Progesterone should balance estrogen, but when progesterone is low estrogen can become chronically high, and over a lifetime this increases the risk of estrogen-driven cancers like ovarian and breast cancer. Both low progesterone and absence of ovulation have been linked with significantly higher risk of breast cancer. 

And, because another role of progesterone is to block androgens, the absence of progesterone only adds fuel to the fire. In this way, PCOS becomes a self-perpetuating cycle. This means it’s very unlikely to just “go away” on its own. 

Is There Hope for Healing PCOS?

I know that this blog post has been really heavy so far. 

Lots of scary symptoms and confusing hormones… that might leave you feeling like “Is there any hope for healing PCOS??”

So let me reassure you right now: there IS hope for healing PCOS!

I speak from personal experience - I was diagnosed with PCOS in my twenties. In fact, it was this diagnosis that really lit a fire in my soul for natural healing. 

Today, my PCOS is well managed. My weight is stable, I have hair on my head, not my face. I was able to get pregnant and give birth to a beautiful daughter. To be totally transparent, we did use IVF - but I had PCOS, was almost 40, and have only one ovary! With those factors in mind, it went as smoothly and easily as it possibly could have - due in large part to the work I had done to optimize my health and hormones.

 Life is good… and I want these kinds of results for you, too!

The rest of this article will be dedicated to healing PCOS.

Step 1 to actually treating PCOS is determining what type of PCOS you have.

The 4 Types of PCOS

While PCOS is the umbrella term, clinically, I see people with PCOS fall into one of four categories based on their symptoms and presentation. 

Knowing what type of PCOS you have is critical because it guides what treatment plan will be most effective for you. 

Read through all four types and see which one you identify most with. 

Type #1: Insulin Resistance PCOS

Insulin Resistance PCOS is the most common type, and accounts for about 70-75% of all PCOS cases. The defining criteria? If a patient has insulin resistance of any degree and PCOS, they have Insulin Resistance PCOS. In addition, if you have pre-diabetes, you likely also are in the Insulin Resistance PCOS category. 

High insulin levels promote high androgens, creating PCOS. 

What years of working with PCOS patients has taught me is that, usually, there is some level of insulin resistance present in people with PCOS, even if it’s subtle. One tell-tale sign I look for are changes in energy levels after eating. In a healthy person, eating should only make you feel less hungry. If eating makes you feel tired and sluggish, or conversely, clears your head and gives you a major boost of energy, that’s a red flag. 

To know if you have insulin resistance, your blood can be tested for high insulin levels using a fasting insulin test. Fasting glucose and hemoglobin A1c blood tests can also help provide a snapshot of your body’s response to insulin. However, sometimes a person has a normal fasting insulin, but still has a poor glycemic response to carbs. This means their blood sugar spikes above 140 or that their insulin resistance is more exaggerated than it should be. To assess this, an oral glucose tolerance test is used. Glucose tolerance tests are preferred because they can catch insulin resistance at lower levels and in earlier stages.

Another option is at-home glucose monitoring with a glucometer or continuous glucose monitor. I love this option because no doctor’s orders are needed (you can get a glucometer and test strips over the counter) and it can provide a bigger picture of what’s happening to your body when you eat real food over a longer period of time. If you want an exact, step-by-step guide to tracking your glucose measurements over the course of 3 days, click here to download my free At Home Blood Sugar Testing Guide.  

Type #2: Inflammatory PCOS

All types of PCOS feature some inflammation, but in Inflammatory PCOS, inflammation is the hallmark symptom, and insulin resistance isn’t present. 

People with Inflammatory PCOS often have known causes of chronic inflammation or other inflammatory symptoms and conditions, like:

• Autoimmune disease
• IBS or SIBO
• Joint pain or body aches
• Chronic headaches
• Chronic fatigue
• Depression
• Skin issues like eczema or psoriasis

Sometimes, Inflammatory PCOS is best diagnosed by ruling out the 3 other types. If you’re feeling uncertain if this type describes you, keep reading about the other types. 

Type #3: Post-Pill PCOS

For some people, stopping hormonal birth control pills can lead to the development of PCOS. Stopping the artificial progesterone in the pill (called progestins) can cause a temporary surge in androgens that creates PCOS. This is most common with Yasmin, Yaz, and the Mirena IUD, although it can happen with other pills 

People with this type of PCOS usually report that their periods were normal before starting the pill, and symptoms only began once they stopped. The good news is that, if treated, this type of PCOS is usually more temporary. Detox support and herbs that lower androgens can often reverse this type. (More on treatments to come.)

Type #4: Adrenal PCOS

Adrenal PCOS is largely genetic, but can also be triggered by extreme stress, weight loss diets, overexercise, and lack of sleep, all of which further tax the adrenal system. 

Adrenal PCOS often looks a lot like congenital adrenal hyperplasia (CAH), which was discussed above. However, unlike with CAH, with Adrenal PCOS, 17-OH progesterone won’t be elevated. In addition, women with adrenal PCOS often only have elevated DHEAS, not testosterone or androstenedione. 

For this type of PCOS, the best approach is supporting adrenal hormone function and managing stress, alone with nutrients and botanicals that help normalize androgens. 

My Treatment Goals for PCOS

When you have any goal - but especially a big health goal like treating PCOS, it’s important to break it down into smaller, trackable, manageable goalposts. 

PCOS treatment isn’t a one-pill-and-you’re-done kind of thing… it can take months of consistent work to see changes. Having clear-cut goals in mind helps power you through the process.

(And we also have health coaches on staff who are specially trained in helping you break down goals and achieve them step-by-step!)

My PCOS treatment goals include:

• Regulating hormone levels (increasing progesterone secretion, LH:FSH, decreasing prolactin)
• Improving the stress response and HPA (hypothalamus-pituitary-adrenal) function
• Optimizing the microbiome
• Optimizing detox pathways and function

What About Standard Treatments?

Two of the most common standard treatments for PCOS are hormonal contraceptives and the drug metformin. 

Metformin is an insulin sensitizing drug that can help with insulin resistance. However, it doesn’t enhance ovulation for many patients. As far as drugs go, I don’t think metformin is a bad one, and it may have some benefit for you. Talk to your doctor about it. But, because metformin tends to displace vitamin B12, be sure to supplement or monitor your levels while using it.

Hormonal contraceptives (aka the birth control pill) are one of the most common “treatments” for PCOS, but aren't one I recommend. That’s because all the pill cna do is further suppress ovulation and hormone production - it does nothing to address the root cause of the imbalance. When you inevitably stop the pill (and all women have to stop the pill at some point, even if only because increased age has made the risk of blood clots too high), PCOS symptoms come roaring back. 

Birth control pills also contain artificial progestins, which actually behave more like testosterone in the body than they do real progesterone. For women with PCOS, this can exacerbate symptoms. 

Furthermore, one of the biggest issues with PCOS is that it suppresses ovulation, and ovulation is necessary for healthy hormone balance, preventing cancer, and maintaining bone integrity. The birth control pill also suppresses ovulation… which means it does nothing to fix the problem. 

Step #1: Testing

Testing is an essential step for my work as a practitioner. But I’m not just talking about the run-of-the-mill tests you’ve likely had before… I use advanced, in-depth testing to get a deep look at what is happening throughout your body.

Here’s some of the tests I commonly use with PCOS patients:

• Testosterone
• SHBG
• DHEA
• Epi-Testosterone
• 5a-Androstanediol
• 5b-Androstanediol
• DHT
• Androsterone
• Etiocholanolone
• Estradiol
• Prolactin
• AMH
• LH
• FSH
• C-RP

I prefer to use the DUTCH Complete test for most of these hormones and metabolites, but they can also be tested via blood serum, as well. Some are only available via serum testing. 

In addition to these, I also run some tests to rule out other conditions and assess overall health:

• 17-OH progesterone, to rule out CAH
• Thyroid panel, to rule out amenorrhea due to thyroid issues, and because thyroid issues often co-occur with PCOS
• Lipid panel, to assess metabolic syndrome and cardiovascular risk

I also sometimes use a month-long cycling panel to assess ovulation, and to look at overall progesterone levels/exposure over the month/cycle, because you can’t assess this with a one day snapshot. To do this, I use the Menstrual Cycle Mapping test from ZRT Labs or the Oova. Oova catches LH surges and can confirm ovulation, even in women with PCOS. This is HUGE because standard ovulation tests can’t detect the LH surge, since LH is already high in women with PCOS. For more on the Oova, read this. The Menstrual Cycle Mapping measures progesterone, LH, and estradiol, which can be really useful in some cases. 

Step #2: Add Lifestyle Changes

The lifestyle changes I have patients implement vary based on their unique case, but there are some general principles that help most people with PCOS.

First, and maybe most importantly: prioritize sleeping 8 hours per night. 

And while I know everyone says this… you also have to find a way to manage stress that works for you. Research has shown people with PCOS actually have a greater stress response than women without PCOS, even when the stressor is the same. It makes women with PCOS more inflamed, and more likely to experience anxiety and depression, too. 

Some of my favorite tools for managing stress:

• EMDR therapy (with a trained practitioner)
• The ApolloNeuro wearable - this uses specialized touch therapy against your skin to promote feeling of calm and well-being. There is nothing else like it available!
• Inaura.com  - a new platform that provides a wide array of therapies to help deal with stress and trauma

In addition, improving diet can help, too. I recommend eating 2-3 meals per day of an organic, plant-heavy diet avoiding gluten, most dairy, artificial sweeteners, trans fat, and alcohol. Eat plenty of healthy fats - like olive, coconut, and avocado oils, plus high quality animal fats, but avoid trans-fats. And if your diet is lower in carbs, be sure you’re including lots of variety of veggies to get the plant fibers your gut microbiome needs to thrive. And, if you’re not overly sensitive to caffeine, add 2-3 cups of green tea daily.

Step #3: Supplement Smart

Most people want to start with supplements, but it’s really the third step, after testing and diet and lifestyle changes. Remember that supplement regimens need to be customized to your needs - so while the ideas here are a great place to start, they can’t replace working one-on-one with a trained practitioner. 

With my own patients, I use the results of their lab testing and the lifestyle changes to create custom, one-of-a-kind supplement protocols, with their specific type of PCOS and symptoms in mind. 

One last thing, more isn’t always better. While all of these supplements have benefits, I usually use no more than 3-5 at any given time. 

Here are some of my go-to supplements:

Magnesium

Magnesium is an essential cofactor for thousands of processes in the body and is especially key for insulin sensitivity. Research has shown people with Type 2 diabetes (which is common with PCOS) may excrete higher-than-normal amounts of magnesium in their urine, and that magnesium deficiency may be associated with the development of insulin resistance - which is another key component of PCOS. 

In addition, magnesium absorption is interfered with by birth control pills, which many women with PCOS have taken or are taking for long periods of time. A good place to start is with this magnesium, 300 mg, twice daily.

Pre and Probiotics

Pre and probiotics promote “good” flora in the gut - prebiotics by acting as food for the gut bacteria, and probiotics by introducing new, beneficial strains. This leads to a greater production of anti-inflammatory Short Chain Fatty Acids (SFCAs), which are a byproduct of bacterial fermentation. SFCAs help improve tight junction function, reducing LPS passing into the bloodstream, which can overstimulate the immune system. 

In an animal study, those with PCOS even showed reversal of PCOS with a microbiome transplant and lactobacillus (a type of beneficial bacteria). In another study, supplementing with probiotics and the mineral selenium reduced excess androgen levels and improved hirsutism.  

My recommended probiotic is MegaSporeBiotic. Be sure to eat plenty of fruits and veggies for pre-biotic plant fibers, or add a prebiotic supplement like MegaPreBiotic. 

Zinc

The mineral zinc has been shown to improve ovarian function, lower androgens, raise progesterone,  and promote ovulation. My recommended brand is Designs for Health and the recommended dose is 30 mg daily. 

Vitex

Vitex is an indirectly progesteronic herb that has been found in some research to benefit PCOS. Vitex can decrease prolactin by stimulating dopamine. Prolactin is often elevated in women with PCOS, and elevated prolactin promotes higher androgen levels. 

While clinically, vitex seems to help many women with PCOS (including me), in theory, it could make PCOS worse. This is because vitex may stimulate LH, and in women with PCOS, LH levels are already too high. However, it is a game-changer for many women with PCOS. If you decide to try it, keep a close eye on your symptoms for signs of improvement or backslide.  Especially consider it if you’ve been diagnosed with elevated levels of prolactin. 

This product is my favorite blend with clinically meaningful levels of Vitex. 

Inositol

Inositol is a plant compound (often thought of as one of the B-vitamins, but technically a sugar) that has been proven beneficial in those with PCOS. One potential mechanism could be that inositol contains the phosphoglycan that helps mediate insulin, and this phosphoglycan is often deficient in people with PCOS. 

Research has shown inositol:

• Improves insulin sensitivity
• ­Improves ovulatory function
• ­Decreases serum androgens
• ­Decreases elevated blood pressure
• ­Decreases elevated plasma triglycerides
• ­Improves oocyte quality in women with PCOS

There are several forms of inositol: most commonly myo-inositol and d-chiro inositol. Both forms were shown effective in improving ovarian function and metabolism in patients with PCOS, although myo-inositol showed the most marked effect on the metabolic profile (i.e. insulin resistance), whereas d-chiro-inositol was better able to reduce hyperandrogenism. Myo-inositol may also protect against gestational diabetes in women with PCOS.

Most commonly, myo-inositol and d-chiro inositol are used in combination, as there is evidence they balance each other and provide the most benefits together. A standard dose is 4 grams daily. This is my recommended brand. 

Licorice & Peony

Licorice and peony are often used together in traditional chinese medicine formulas, such as Shao Yao Gan Cao Tang. Research has shown they block the production of testosterone and promote aromatization, which converts testosterone to estrogen. Licorice in particular can help lower testosterone and block androgen receptors. They may also improve low progesterone, and modulate estrogen and prolactin. 

N-Acetyl-Cysteine 

­N-Acetyl Cysteine (NAC) is a powerful antioxidant that works to reduce inflammation and oxidative stress in the body, both of which may be higher in women with PCOS. NAC promotes antioxidant activity by increasing the production of glutathione, which studies have shown women with PCOS have 50% less of than normal. 

NAC can help lower testosterone and improve insulin resistance. One study even showed NAC was more effective at reducing insulin than the drug Metformin (more on this to come). 

For women with PCOS looking to become pregnant, NAC may be especially important. Women with PCOS who took NAC were 3.5 times more likely to become pregnant, had a greater likelihood of a live birth, and reduced risk of preterm delivery. 

In women using the drug Clomid to promote fertility, adding NAC improved ovulation rate, cervical mucus, mature follicles, endometrial thickness, follicular E2 levels, and luteal progesterone levels. 

My recommended brand is Designs for Health, 900 mg, 3 times daily. 

Berberine

Berberine is an herb that can benefit women with PCOS in many ways. First, berberine can improve insulin resistance in theca cells. It has been shown to be particularly effective against obesity and visceral adipose tissues (hormonally active fat). It also improved ovulation and increased fertility. Berberine was shown to reduce testosterone and improve LH:FSH rations compared to placebo. 

Berberine may also benefit the gut microbiome of women with PCOS by increasing production of Short Chain Fatty Acids (SFCAS - for more on this, see Pre and Probiotics, above). 

I like this brand of berberine. 

Reishi

The mushroom reishi blocks 5-alpha reductase, which is the enzyme that converts testosterone into its stronger metabolite, DHT. This can help reduce overall androgen excess in women with PCOS. Reishi is also beneficial for the hypothalamic-pituitary-adrenal axis, as well. 

My favorite reishi supplement is Mushroom Science Reishi, dose is 2 capsules, twice daily.

Gymnema

Gymnema is an herb that has insulin-modulating activity in those with PCOS, and can reduce elevated triglycerides, which are often also associated with PCOS. 

**Important-- Gymnema is not for use during pregnancy or lactation. 

Chromium

Chromium picolinate is an essential trace element that is particularly beneficial for insulin-resistant types of PCOS. Research has shown chromium had effects comparable with the drug metformin on ovulation and pregnancy rates, and was better tolerated. 

I recommend Thorne Chromium Picolinate, 1000 mcg a day.

­Saw Palmetto 

Saw palmetto is an herb that can block prolactin receptors on ovarian cells, helping to reduce excess androgens. 

Designs for Health Prostate Supreme 2 capsules twice daily. 

Bioidentical Progesterone

Using bioidentical progesterone can lower androgens and LH, leading to less ovarian testosterone production. It also blocks 5-alpha reductase, the metabolite that converts testosterone into the more potent DHT, which is often elevated in PCOS. Bioidentical progesterone also slows the and GnRH pulses that are too rapid in people with PCOS, helping to treat the actual root of PCOS.

This is one of my top choices for every woman with PCOS - but be sure to work with a practitioner on this one, as bioidentical progesterone requires specific dosing to be effective and safe. 

One thing to note is that adding bioidentical progesterone is not the same as starting a hormonal contraceptive (birth control pills). Birth control pills do not contain bioidentical progesterone - instead they contain artificial progestins, which actually behave more like testosterone in the body. 

PCOS Is Complicated, But There Is Hope!

As you can tell by the length of this article, PCOS is incredibly complex. (And I could have written so much more!)

But if you take away only one thing, I hope it’s this: there is hope for effectively treating PCOS.

You don’t just have to suffer through and try to cover up the symptoms. With the right care, you can find and address the root cause.

If you’re ready to start treating your PCOS from the root cause on up, I’d be honored to help guide you there. Having struggled with PCOS myself, helping other women with the condition isn't just my job. It is my passion!

Just click here to book a FREE, no-obligation 15-minute consultation with my team. We use these short calls to get to know you, your health concerns, and see if working together would be a good fit. Think of it like a first date. 

>>> Book a Free Consult <<<

Brie

PS - Overwhelmed with all the info on PCOS? I know how that feels, and I’d love to help you find a customized plan (diet, lifestyle, supplements) to help manage PCOS and achieve your health goals. Book a free consultation here so we can chat about a plan for you. (No obligation!)

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by Bassem