Polycystic ovary syndrome is incredibly challenging. Woman generally present with a myriad of symptoms ranging from acne (especially cystic), infertility, blood sugar problems, excessive hair growth on face, irregular and painful periods, trouble losing weight. It is possible to have a few of these symptoms, or all of these symptoms, depending upon how far the PCOS has progressed.
The Rotterdam Criteria
Only two of the three criteria are necessary for a PCOS diagnosis:
- Delayed ovulation or menstrual cycles
- Hyperandrogenism/high androgenic hormones like testosterone
- Polycystic ovaries on ultrasound
Standard medical treatment really only looks at treating the symptoms of PCOS.
For example: A patient presents with cystic acne. Most likely the protocol will be long term antibiotic use including but not limited to: minocyclline and Tetracyclin, tertinoin, topical antibiotics, and benzoyl peroxide. Patients become encouraged because these can, or tend to, help a little. However, once the patient stops taking antibiotics the acne will likely return with a vengeance. Many physicians do not look deeper at the underlying hormones at play. Perhaps the root cause could be a blood sugar imbalance causing the improper production of androgen hormones in woman? It is very common to have symptoms of PCOS but not be able to meet the criteria for diagnosing PCOS because it is still in its earlier stages. In earlier stages, it is much easier to treat and get a reverse of symptoms/disease process.
Another example: In patients where the menstrual period tends to be irregular, the standard medical treatment leans heavily towards prescribing birth control or a statement to the effect that it is unnecessary to have a period every month and to not worry about it. The birth control can be helpful at bringing some semblance of regularity to the menstrual cycle but as a general rule the PCOS patient still feels terrible. The reason for this is because the production of excess androgen has still not been addressed.
The traditional medical model can help control the symptoms but it doesn’t get to the root of the problem. Functional medicine takes a look at the body as a whole and a more holistic approach to see how all of the body systems are functioning and what differences are found in hormone production.
Another approach often taken by conventional medical practitioners is addressing blood sugar dysregulation using a pharmaceutical called metformin. In these scenarios the patient is often struggling to lose weight and on running standard blood tests like a CMP (Complete Metabolic Panel) the glucose and Hemoglobin A1C tend to be elevated. Metformin is the obvious choice.
How Functional Medicine Treats PCOS
A typical protocol often looks like:
- Balance blood sugar (determine insulin resistance)
- Detoxify the liver
- Change diet
- Address causes of inflammation
- Underlying infections
- Determine gut bacteria health
- Balance hormones
- Decrease androgen production
In our practice we first like to figure out the root cause of the problem. Whether fully blown diagnosable PCOS is present, or if the symptoms are early and you only have none or 1 of the Rotterdam criteria, we can easily identify and treat the problem. In the early stages of excess androgen production and insulin resistance (progressing to PCOS) we see patients that have tended to be fit woman, with blood sugar symptoms and functional dysregulation on their blood work, cystic acne and irregular periods. As a general rule, they have already been through a conventional medical model, tried antibiotics both topical and internal, and birth control. Often, they have been told that nothing is wrong with them. These women do not always fit the full blown picture of PCOS. They have early or functional PCOS. They have most of the markers: elevated androgens, slightly dysregulated glucose, irregular periods and cystic acne. The conventional medical model has failed and they end up in our practice looking for answers. General complaints are often, “I am in my twenties, why do I still have acne” or, “We have been trying to get pregnant for a while but it isn’t working.”
Balance Blood Sugar (Determine Insulin Resistance)
At the beginning of treatment we will evaluate past lab work, or will order new labs if the previous ones were run longer than six months ago. 85- 90% of the population has issues with glucose regulation (hypo/hyper). Depending on the severity of the PCOS symptoms, or disease progression, a patient always has one of the two blood sugar issues, hyper or hypo. People tend to only associate blood sugar issues with diabetes. That is absolutely incorrect. PCOS patients will tend to have symptoms from one of the two categories below.
Hypoglycemia (Low Blood Sugar)
- Shakiness when hungry
- “Hanger” – irritable when hungry (hungry + angry)
- Can’t stay asleep/sleep through the night
- Crave coffee or candy in the afternoon
- Moods of depression or melancholy
- Chronic fatigue/low energy
Hyperglycemia (high blood sugar)
- Extreme thirst or hunger
- Feeling hungry even after a meal
- Frequent or increased urination
- Tingling sensations in your hands or feet
- Feeling more tired than usual
- Frequent infections
- Fatigue after eating
Detoxify the Liver
Much of the time these patients are showing slightly fatty liver. On their lab work their liver enzymes are slightly elevated. The liver filters the hormones and helps to convert them to the finished active hormone production. If the liver isn’t functioning correctly it makes sense that there can be an excess of hormones. If a patient has fatty liver it is challenging to convert hormones and the body is less effective at detoxifying all of the chemicals that we can be exposed to on a daily basis. In fact, some studies have shown that we can be exposed to 85,000 chemicals every 7 days. Only a small portion of those chemicals have been studied (⅓ at most). Of the chemicals that have been studied, many have been shown to be endocrine disruptors. That means that they can adversely affect the hormone systems including but not limited to: thyroid, adrenal and the female reproductive system.
Symptoms of fatty liver:
- Itchy skin
- Bowel movements difficult or painful
- Trouble digesting fatty meals
- Sensitivity to smells
- Feeling queasy
- Headache over the eyes
Change Diet to Reduce Inflammation and Balance Blood Sugar
PCOS responds very well to dietary changes. Depending upon how chronic the case, diet can have a major positive impact on PCOS symptoms and help with the reversal of PCOS. It definitely is a piece of the puzzle that can’t be overlooked. Since most of these women have some form of blood sugar dysregulation, most with insulin resistance, and inflammation, controlling what they’re putting into their bodies and how often, is very helpful at stabilizing blood sugar. We have seen some evidence that when a woman’s blood sugar dysregulates it is possible to over produce androgens. So stabilizing this pathway really helps to decrease the overproduction of androgens.
Initially, we will recommend an anti-inflammatory diet. Most of the patients that come into our practice are well educated and have tried some variety of an anti-inflammatory diet. At this point we move forward into an elimination diet. We want to find the offending food or foods causing the inflammation. It is critically important to figure out all of the foods the patient is reacting to that sometimes we choose to run blood tests to determine food sensitivities. Elimination diets done correctly are challenging, but it is our mission with PCOS to figure out what the patient is reacting to.
- Underlying infections
Most patients, in general, have compromised gut integrity. This comes from poor diet, stress, or overuse of antibiotics. When we use antibiotics they decrease the health of our gut bacteria, which is critical for digestive health and gut permeability. It is important to get the gut bacteria in balance so it can adequately breakdown and absorb the food and nutrients being consumed. If food is not able to be broken down then the pieces of food are too large. This can contribute to the food causing gut permeability if the pieces are too large in the intestine and not readily absorbed. This also leads to food sensitivity and potentially food allergy. If the gut can be healed, inflammation can be reduced, foods causing problems can be identified, then the patient feels much better. and it helps both with blood sugar dysregulation because you are breaking down and absorbing food. This also decreases systemic inflammation cause the body problems.
Balance Hormones and Decrease Androgen Production
- Unwanted hair growth (primarily face)
- Dysregulation of periods
- Hair loss
- Deep voice
Another thing that sets functional medicine apart from conventional PCOS treatment – we run full panel blood tests including hormone tests (which are rarely run). This gives us key insights to what is going on inside the body. The reproductive hormones tend to be the first system to become dysregulated. The reason for this is because we do not need that system to sustain our own life. If we are not well, our body creates a protective mechanism by not allowing us to become pregnant because we need to work on other body systems before we can sustain another life. Woman often come into the office desperate at this point. They feel beaten down because they are having miscarriages or inability to get pregnant. The have gotten advice that they are “too old” or “fertility treatment is the only treatment left to do.” The bottom line is the other provider has come up short on answers. The last thing we adjust or supplement in these cases are the hormones, because as the other body systems come back into balance the hormones can naturally recalibrate. In all PCOS cases, it is important to decrease the androgen production.
Other factors also contribute to PCOS like adrenals, thyroid, female reproductive hormones (estrogen and progesterone). All of these are evaluated on a case by case basis and we determine how to best manage the conditions.
PCOS has a lot of variability when it comes to treatment and what systems in the body have become an issues. Each individual needs to be addressed case by case. We do this by having all patients fill out extensive questionnaires that gives us insight into all organ systems like liver, adrenal, thyroid, hormones, blood sugar, etc. We also use specialized lab work to help identify the order in which we need to treat.
We are passionate about helping PCOS. I have had my own battle with hormone issues, not to fully blown PCOS, and I have been through what most of my patients are going through.
My Personal Story
As a teenage I had acne. I went to my MD, who prescribe me Differin and recommended accutane. I then went to a dermatologist who did chemical peels and laser treatments. None of these avenues worked. I thought my acne was a lost cause. All the doctors told me I was perfectly healthy and I would just magically grow out of it. As a junior in high school I woke up with debilitating period cramps, which I was told were normal. Today, I wouldn’t quite stand straight up. I told my Mom I still wanted to try to go to school but she refused and took me to the doctor who was insistent I go to the ER. It seemed that in this perfectly healthy girl, my appendix was exploding. No one ever thought to ask me about how my periods were linked to my hormones, blood sugar or gut (which were all a problem). Natural medicine was the only thing that ended up having answers for me. I went through all of the traditional medicine routes, which continuously failed me. I just wasn’t “sick” enough to need it for my acne, blood sugar, and hormones. Had I gotten answers sooner and started the functional medicine process, I might still have my appendix. I am not anti conventional medicine, I just believe in an integrative approach depending on the progression of the disease. I think in the grey area, medicine doesn’t have all the answers until it progresses to disease. I’ve lived what I now recommend.