Polycystic ovary syndrome is a common hormonal condition affecting many women of reproductive age worldwide. In the United States, it affects approximately 7% of women. PCOS is associated with challenges related to fertility and may increase the risk of certain cardiovascular and metabolic conditions. Managing PCOS can be costly, with billions spent annually on healthcare related to the condition and its associated health concerns. Given these statistics, PCOS is a significant women's health issue that requires attention. (7, 23)
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What is PCOS?
Polycystic ovary syndrome (PCOS) is a common hormonal disorder that affects women of reproductive age. It is characterized by a combination of symptoms, including irregular menstrual cycles, higher levels of male hormones (androgens), and multiple small cysts on the ovaries. PCOS can disrupt the normal hormonal balance in a woman's body, leading to a range of manifestations such as irregular menstrual cycles, challenges with fertility, acne, increased hair growth, and weight gain. (17)
PCOS Symptoms
According to the Rotterdam Consensus, PCOS can be identified with the presence of at least two of the following three criteria:
- Chronic ovulatory dysfunction
- Hyperandrogenism
- Polycystic ovaries (as visualized on imaging): at least 12 follicles measuring 2-9 m in diameter and/or an ovarian volume of at least 10 mL in at least one ovary
Chronic ovulatory dysfunction can be indicated by irregular menstrual cycles (oligomenorrhea), the absence of menstruation (amenorrhea), and the absence of ovulation (anovulation) (16).
Hyperandrogenism can be identified clinically by the presence of excessive acne, androgenic alopecia (hair loss), or hirsutism (male-pattern excessive hair growth); or chemically by elevated serum levels of total, bioavailable or free testosterone or dehydroepiandrosterone sulfate (DHEA-S).
Metabolic symptoms are also common in individuals with PCOS due to the insulin resistance associated with the condition, including high blood sugar, high cholesterol and triglycerides, high blood pressure, and excess body weight. (3)
What Causes PCOS?
One of the primary factors contributing to PCOS is hormonal imbalance, specifically involving insulin and androgens. Insulin resistance, a condition in which the body does not respond effectively to insulin, can disrupt normal hormone regulation and may lead to the ovaries producing higher amounts of androgens. These male hormones can interfere with the ovulation process and may result in the formation of cysts in the ovaries. The elevated levels of androgens also contribute to the characteristic symptoms of PCOS, such as acne and increased hair growth. (3, 17)
Genetics may also play a role in the development of PCOS. Studies have identified several genes that might contribute to the risk of developing the condition. These genes are involved in hormone regulation, insulin action, and the production of androgen receptors. Having a close family member with PCOS may increase the likelihood of developing the condition, suggesting a hereditary component. (7, 13)
Environmental and lifestyle factors can also contribute to the development and severity of PCOS. Obesity, a sedentary lifestyle, and poor diet may exacerbate insulin resistance and hormonal imbalances. Excess body weight can amplify the production of insulin, potentially aggravating the symptoms of PCOS. Additionally, high stress levels, inadequate sleep, and exposure to endocrine-disrupting chemicals may further disrupt hormone regulation, potentially increasing the risk of PCOS. (9, 13)
Functional Medicine Labs to Test for Root Cause of PCOS
Functional medicine testing can help healthcare providers holistically evaluate individuals with PCOS. Using various lab panels aids in assessing the multiple organ systems that influence and can be affected by PCOS.
DUTCH Test
The DUTCH panels are some of the most commonly used hormonal panels by functional medicine practitioners. The DUTCH Plus and DUTCH Complete panels require several urine and salivary collections over one day to measure estrogen, progesterone, androgens, cortisol, organic acids, and their respective breakdown products. These tests analyze how the body makes and metabolizes reproductive hormones and can provide insight into underlying causes of stress responses and sleep patterns.
The DUTCH Cycle Mapping test may be advantageous over the other DUTCH panels for individuals with PCOS because it follows estrogen and progesterone levels throughout an entire cycle to map out hormonal patterns associated with the various phases of the menstrual cycle. Unlike single-day tests, this panel can better evaluate patterns associated with anovulatory cycles, as is typical with PCOS.
Serum Hormonal Testing
Estrogen, progesterone, testosterone, and DHEA can also be measured in the serum. Some providers prefer assessing hormones via the serum; however, single blood tests cannot provide insight into how hormones fluctuate throughout the menstrual cycle, nor do these results help evaluate hormonal metabolism. Measuring sex hormone binding globulin (SHBG) with testosterone helps identify how much testosterone is bound in circulation, rendering it inactive. In PCOS, SHBG levels are often lower than optimal (17).
Additional hormones are often ordered for individuals with suspected PCOS because specific hormonal patterns are commonly seen in these individuals. Although these hormones are not required for diagnosis, they can help to confirm a PCOS diagnosis clinically. Prolactin is often elevated in individuals with PCOS (17). In healthy women, the ratio between LH and FSH usually lies between 1 and 2; in women with PCOS, this ratio becomes reversed and might reach as high as 2 or 3 (10).
Follicular cells of the ovaries produce anti-Mullerian hormone (AMH), which can correspond to a woman's ovarian reserve (2). Given the polycystic nature of PCOS, the level of AMH is often higher in women with PCOS compared to that in healthy women of childbearing age.
Thyroid Panel
Thyroid function can influence the healthy cycling of reproductive hormones. Women with PCOS may be more likely to develop subclinical hypothyroidism and autoimmune thyroiditis (20). A thyroid panel, including TSH, total and free levels of T4 and T3, and thyroid antibodies, can be ordered to screen for thyroid conditions.
Cardiometabolic Panel
Given the potential increased risk, a comprehensive cardiometabolic panel may include a lipid panel, diabetes panel, hs-CRP, vitamin D, and CMP to screen for dyslipidemia, hyperglycemia and insulin resistance, and kidney and liver function.
Comprehensive Stool Analysis
Dysbiosis has been associated with insulin resistance and ovarian function. Therefore, gut function testing and microbiome assessment may be considered with a comprehensive stool analysis as part of a root-cause diagnostic evaluation of PCOS.
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Conventional Treatment for PCOS
Conventional medicine often uses pharmaceutical medications to address common health concerns related to PCOS symptomatically. Weight management is often suggested for individuals who are overweight. Clomiphene and letrozole are commonly used medications for fertility support to help induce ovulation. Metformin is often used to help manage blood sugar levels. Hormonal contraceptives (i.e., oral contraceptive pills, dermal patches, or vaginal rings) may be used to help regulate menstrual cycles and manage dermatologic manifestations. (23)
Functional Medicine Treatment Protocol for PCOS
While the above medications can be helpful for managing symptoms, they may not address the underlying factors associated with PCOS. Therefore, discontinuing any of the above medications might result in the return of symptoms. Functional medicine aims to support the body's natural processes by focusing on reducing inflammation, supporting insulin sensitivity, and promoting hormonal balance to encourage regular ovulation and glucose metabolism.
Therapeutic Diet and Nutrition Considerations for PCOS
Diet can be an important part of supporting ovarian health, fertility, and metabolism. Therefore, dietary guidance may be offered to individuals with PCOS as part of a comprehensive approach. A 2022 systematic review and meta-analysis suggested that low-carbohydrate diets may help support hormonal balance for individuals with PCOS. Positive laboratory findings associated with a low-carb diet include: increased SHBG and decreased AMH, free androgen index, and total testosterone. Additionally, individuals may experience increased rates of clinical pregnancy, regular ovulation and menstruation, reduced miscarriage, and improved clinical symptoms of hyperandrogenism. This review also noted that the magnitude of improvement and duration of dietary compliance were directly related. (15)
Additionally, specific patterns in meal timing and distribution can significantly influence clinical outcomes in individuals with PCOS. High-caloric intake at breakfast with reduced intake at dinner, compared to skipping or eating a low-calorie breakfast and a high-calorie dinner, may support insulin sensitivity and ovulation rates. (8)
Supplements Protocol for PCOS
Consider exploring the following dietary and herbal supplements as part of a holistic approach to support positive outcomes.
OvaBlend™
Vitanica's OvaBlend™ combines several ingredients that may support healthy blood sugar regulation and ovulation. Highlighted ingredients of this formula include:
- Green tea may help reduce inflammation and support SHBG levels.
- Chromium, cinnamon, and NAC may support healthy glucose metabolism and improve insulin sensitivity.
- Saw palmetto may help inhibit the conversion of testosterone to dihydrotestosterone (a stronger form of testosterone); this may support reductions in hair loss and acne.
Dose: 2 capsules three times daily
Duration: 3 months
Ovasitol®
Myo- and D-chiro forms of inositol are often explored for PCOS, given research suggesting inositol may support ovulation, hormonal balance, and metabolic markers. Additionally, inositol is associated with more regular menstrual cycles. Ovasitol® contains a combination of myo-inositol and D-chiro-inositol in the body's naturally occurring ratio of 40:1. Research suggests taking these two forms, in this ratio, may be more beneficial than taking either form of inositol alone.
Dose: 4,000 mg daily
Duration: 3 months
Vitamin D
Vitamin D may help modulate immune and inflammatory pathways, blood sugar, and ovarian function. Vitamin D deficiency has been associated with insulin resistance, inflammation, and women's hormonal conditions. (3, 21)
Dose and Duration: determined by laboratory values; typical maintenance doses range from 2,000-5,000 IU daily
When to Retest Labs
Substantial shifts in hormonal patterns may be observed three months after initiating a treatment protocol, although many individuals may begin to notice improvements before this. Functional medicine practitioners generally wait 3-6 months after starting a treatment protocol to follow up with individuals and reorder labs to assess the efficacy of and the individual's response to the treatment plan.
Learning More About PCOS
- Magazine Article: Top 6 Functional Medicine Labs to Test for Root Cause of PCOS
- Magazine Article: Why Do Some Women Get Ovarian Cysts?
- Pre-recorded Class: How To Use The Dutch Test for PCOS
- Podcast: Empowering Women with PCOS: A Functional Medicine Approach with Dr. Natalie Underberg
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Summary
Polycystic ovary syndrome is a common women's health concern associated with significant medical challenges. While conventional medicine offers tools to manage the symptoms of PCOS, functional medicine practitioners use advanced diagnostic testing to explore the root of hormonal imbalances and insulin resistance that may contribute to PCOS and its various associated conditions. It is possible to support hormonal and metabolic health using functional medicine, potentially alleviating the symptoms associated with the condition.
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