PCOS Basics with Dr. Patti Haebe
We're talking about PCOS today, polycystic ovarian syndrome.
This is one of the most common disorders of premenopausal women. About 3 million people in the US have it. I wouldn't be surprised if more than that do honestly.
What's interesting about PCOS is it tends to be a diagnosis of exclusion, after you eliminate any other secondary causes of anovulation or hyperandrogenism. A lot of times doctors are going to make sure you don't have a condition called hyperprolactinemia - where your brain is creating too much prolactin, hypercortisolism, late-onset congenital adrenal hyperplasia, Cushing's syndrome, thyroid disorders, or even adrenal androgen-producing neoplasms. So there's some investigation that can take place when you're not ovulating and having these irregular cycles. But typically, you end up kind of getting thrown in this PCOS category.
So talking about PCOS, you might have heard of the Rotterdam criteria for having PCOS. There's also an NIH (National Institute of Health) criteria. What it means is there's ovarian dysfunction. So, there's some sort of irregular or absent ovulation. And then there's clinical evidence of androgen excess. Androgen excess is high androgens, which are male dominant hormones. This is testosterone, DHEA and DHT and androstenedione-- those are the main ones that cause symptoms such as hirsutism. And acne hirsutism is the growth of dark hairs, either on the upper lip, the chin, nipples. . . not the places that we typically see in women. Additionally, the criteria also include the presence of more than 12 follicles in each ovary, measuring two to nine millimeters in diameter. This doesn't have to be present to make the diagnosis of PCOS; it's just one of the criteria.
The NIH criteria is super similar. It's the presence of ovulatory dysfunction -- menstrual cycles that are longer than 40 days -- and mid-luteal serum progesterone of less than five nanograms per milliliter, which indicates that you're likely not ovulating. That can also be present in people with a normal cycle. And in addition to that, hyperandrogenism: high testosterone, high DHEA/DHT levels.
The above-mentioned is related to insulin based PCOS. And that's the most common form: high testosterone levels, sometimes issues with insulin levels and hemoglobin A1C being off. And it can cause weight gain, depression, acne, hair loss, dark hair growth, and irregular periods.
But I also see something adrenal-based -- which is sort of a new term -- and it doesn't technically have a terminology, I call it an adrenally-based PCOS, which stems more from an issue with the adrenal glands overreacting to stress and attempting to keep up with adequate cortisol production because you're chronically stressed. And that looks like this: people with irregular cycles that may not be overweight, have normal blood sugar levels, and maybe they don't have high testosterone, just high DHEA.
We'll address this again below, but, understand that PCOS is a diagnosis -- great. But what's important is what's going on in your body, hormonally, that can be fixed to get you where you need to be. The diagnosis is one piece of the pie, and whether you want to put a name on something or not, you can still look at imbalances and say what needs to be fixed -- what's off.
What can I do to reduce facial hair? How do I lower my testosterone levels?
When we're looking at facial hair, this is a lot of times caused by something called the hormone DHT. DHT is created from testosterone and via something called the five alpha-reductase pathway. This is when your body has high levels of testosterone, and it's over-converting into DHT.
Unfortunately, the dark hairs that are there are there to stay. What is important to focus on is preventing more dark hairs from growing and making sure we're getting those testosterone levels under control as soon as possible. That being said, there are two answers to this question. The first is: if you already have those dark hairs present -- and it's important to approach the root cause -- but likely, you're going to need something like electrolysis or laser hair removal to permanently remove those dark hairs.
Now, the other side is the prevention of preventing more dark hairs from coming in: we want to diminish androgenic levels. Some prescriptions can help decrease testosterone levels, decrease the testosterone conversion. A lot of people sometimes take something called spironolactone -- which was actually a diuretic that has anti-androgenic effects as a bonus -- but also with herbs. There's one called Saw Palmetto, and it targets directly that five alpha-reductase pathway that converts testosterone to DHT. So, that herb does a good job in decreasing those kinds of icky androgenic side effects.
In addition to that -- to decrease your testosterone levels -- we need to make sure that we are addressing your blood sugar levels as well. I'm going to explain how your blood sugar ties into testosterone because it seems kind of like a far stretch.
What is the difference between polycystic ovaries and PCOS?
It's exactly how it sounds. Polycystic ovarian syndrome is a combination of symptoms that cause this syndrome. You can have polycystic ovaries from different causes. But many times if you have polycystic ovaries, it's associated with polycystic ovarian syndrome. Basically, PCOS is a condition in which the egg may not develop as it should, or an egg may not be released in ovulation as it should, leaving polycystic ovaries.
Can you have a mild case of PCOS? If so, how can you tell?
There are a couple of different kinds of PCOS, and just because you don't have that stamp diagnosis doesn't necessarily mean that things aren't going on and you're not noticing odd things with your cycle or conceiving. You only need one or two of these criteria to be technically diagnosed with this, but keep in mind: a diagnosis doesn't mean a cure. If you're having irregular cycles, that's your main thing. It's worthwhile investigating where your hormones are, where your blood sugar is, and just digging deeper to look for that cause. So yes, you absolutely can have a mild form. And, there are two different types of PCOS. You don't have to fit into a specific category necessarily.
Someone asked: “ I've been diagnosed with PCOS and have insulin resistance and high testosterone type of PCOS. I also have low iron, so probably close to anemia, low vitamin D, but I am taking supplements." She says she knows she ovulates, her luteal phase is about 15 days, but she's still not getting pregnant. Is there something else she should be considering or get tested?”
This is a great question. You're on the right track, but changes are going to take time. So, I would expect three to six months of consistent change to see improvements in your cycle in really moving the needle on those lab values that are off. Additionally, this person said that they're taking supplements, but it's hard to know which ones they are taking. If they're just talking about iron and vitamin D -- while they're super important for your health to have optimized -- it doesn't necessarily relate directly to PCOS.
So, you need to make sure that you're doing things that are actually targeting it: are we decreasing testosterone levels? Are we balancing blood sugar? Are we supporting healthy ovulation? Just because you're taking a supplement doesn't necessarily fix something; you have to be using it at therapeutic levels to make the changes and help the body heal the way it should.
In addition to this, are you tracking your basal body temperature along with LH strips? We need to make sure we actually know that you are ovulating. So it's important to have all those confirmatory pathways in check. We've talked about LH trips and the importance and value of them. But there's also the importance of continuing with the basal body temperature to confirm that spike, to do progesterone test strips around day 21 (five to seven days past ovulation) to make sure that you really are ovulating.
In addition to this, if you think you are ovulating -- you know you have these PCOS symptoms, but you are ovulating -- and you're not getting pregnant. . . what else do we need to investigate?
Has your partner had a semen analysis yet? Have we investigated your thyroid? How's that working? Have you had a hysterosalpingogram? Are your tubes open? Have you had an ultrasound? Does your uterus look good to go? Is it in a good position? Are there any fibroids or polyps or abnormal uterine positioning that might be preventing implantation?
I always say using the Premom app and tracking with the LH strips, basal body temperature, cervical mucus. . . these all give us clues to what's going on. If everything's looking perfect there, what other things could be causing an issue? It really lets us dig in and look for the root cause.
Can a woman with PCOS take ovulation tests, which are LH test strips?Why or why not?
Absolutely. But if you aren't ovulating, you are not going to see that LH spike. That being said, it's a good idea to always be testing with the LH strips. I know it's hard -- especially when you have long cycles -- you're taking those LH strips for so many days. But it gives you such good information on your LH so you can work with fertility awareness method instructors, and they can look at those LH strips and see: Are you spiking a little bit? Are we seeing your body trying to ovulate, and it's just not quite getting there? Are you getting a gradual spike, and a big one, and eventually ovulating? So, it's important to stay consistent and tracking with those LH strips. That's why I like the easy@home strips because they're affordable, and they're a lot easier to use for a lot of days in a row to get an idea of what's going on with your cycle.
In addition to that, checking your basal body temperature, cervical mucus and progesterone testing are also super important, just so we know what the heck is going on with your cycle. So the more data you can collect about what's going on with your body, the more information you have for figuring out what's going on.
What is considered high androgen levels? (Testosterone or DHEA is what they're looking at.)
If you want numbers, we'll get nerdy, we'll talk numbers! DHEA levels: we're looking for levels more than 240 in females. That being said, DHEA is a super important hormone in your body, and that is a precursor to so many other hormones. That includes your male hormones, your female hormones, progesterone . . . it feeds into and helps create cortisol; it's like a good precursor. I don't like to demonize it, but we do want it within normal levels, and if it's too elevated, a lot of times I'm going to be looking at the adrenals and seeing how stressed out somebody is and see what's causing that rise. Testosterone levels typically should be between - free testosterone should be between 4 and 10 and total should be 40 to 100. So, if you're more than 100 -- or more than 10 free testosterone -- then we need to start looking into things, because those levels are important.
That being said, it's also important that we look into the hormone DHT, dihydrotestosterone, because this is that kind of nasty hormone that we get that causes not only dark hair growth around the lips, the chin, and the nipples, but it also causes male and female pattern baldness, so you can start losing hair around here. So DHT is another hormone that you'd want to check out as well with PCOS that is not as commonly checked. That's a little doctor tip for today!
In addition to sex hormones, it's important to look at that hemoglobin A1C; it's such an important component of PCOS. If your blood sugar is off and you develop insulin resistance, this is what can cause high testosterone levels. So, I always say, if your hemoglobin A1C is 5.6 or higher, we need to do some work on your diet and get those healthy insulin levels in check.
If you have not been diagnosed and have no symptoms of PCOS, is it still possible you could have it?
Yes. I'm assuming this probably means this person has irregular cycles, and maybe their testosterone isn't sky-high. But could they still have PCOS? Yes, absolutely. And again, it comes down to "Do you need the diagnosis to figure out what's going on?" Not necessarily. Dig in. Let's figure out why you're having wonky cycles.
Do carbs and sugar really affect fertility for people with PCOS?
Yes, big, big, big, big time. Insulin resistance is the most widely understood explanation for PCOS to date. So women with polycystic ovarian syndrome possess selective resistance to insulin. Insulin has an action on the theca cells in the ovary. By being stimulated, excess androgens create these clinical signs of PCOS, and the testosterone that's created by the extra insulin triggering these theca cells making that extra testosterone stop follicular development, stops these eggs from forming. It also decreases the development of the endometrial lining in your uterus. So it's hugely important, in that insulin resistance and testosterone balance are super interconnected, and they create that chain reaction that does halt ovulation. Super important to keep carbs and sugar to a minimum. Really focusing on good whole foods. Paleolithic diets are really helpful. Really focusing on meats, veggies, and fruits that are low glycemic, staying away from things like bananas, mangoes, papayas -- focusing on lower glycemic fruits like berries, and just really focusing on balancing that blood sugar.
** Always talk to your doctor before making any dietary or lifestyle changes, this should not be misconstrued as medical advice.**
What tests are conducted to determine if you have PCOS?
So, we already talked about this a moment ago: they're going to look at testosterone, DHA, hemoglobin A1C. They might look at just your serum insulin levels, serum glucose -- as well as an ultrasound -- to look for those multiple follicles or cysts in your ovaries.
What is the best way to track ovulation when you have PCOS?
Basal body temperature, luteinizing hormone strips, just like everybody else. You're just going to have to do it for longer than other people because you have longer cycles, and not every cycle you're going to be ovulating. So don't give up if it doesn't happen -- one cycle, it could be you're skipping cycles, it could be every third, but keep tracking and getting that data months and months and months. The more information you have, the more answers you can find, especially when you work with an expert.
Myo-inositol -- what does it do? And how much is recommended? D-chiro inositol -- is it a good supplement to take for PCOS?
First of all, I'm a doctor, but not your doctor. So everything we're talking about here today is education for you, and just make sure you chat with your doctor before making any changes or investigating anything. But I do want to talk about myo-inositol because it is studied very well in fertility. There are two forms of it: there's d-chiro and there's Myo-inositol. It's an isomer of a sugar alcohol, which is part of a B vitamin group. What Myo-inositol does is regulate the secretion of the pancreas and the ovaries. This is going to mediate the effect of insulin in PCOS patients and going to help decrease those androgen levels, it's going to help support ovulation. It's been studied and associated with good egg quality. And typically studies that I've referenced have been 2000 to 4000 milligrams a day, usually 4000 milligrams in divided doses with minimum side effects. So it's definitely something to chat with your doctor about.
There was a study; it used myo-inositol compared to metformin, which is also an insulin-sensitizing drug.(which is a great one, and it's very effective). It compared 120 women who did 1500 milligrams a day of metformin, and four grams a day of myo-inositol. The metformin group -- they had a 50%, spontaneous ovulation rate and had a 36.6% pregnancy rate, which is awesome. In the myo-inositol group, though, they had an even higher spontaneous ovulation at 65% and an even higher pregnancy rate of 48.4%. Kind of a cool way that nutrients can actually do a really good job and sometimes perform a little bit better, depending on the needs of other things. Also, I see myo-inositol and metformin used together in conjunction, when used under a doctor's supervision. Great question about myo-inositol.
Some people like d-chiro inositol; I like a little bit of d-chiro mixed in with myo-inositol. A lot of the research I've seen supports primarily just myo-inositol, so there's your biochem lesson for the day. But that's a super good one for PCOS. And I do think it's gaining popularity. But again, when it comes to supplements, always talk to your doctor first and make sure you're being safe. Always buy from trusted sources to make sure you know what you're getting. It's just another important thing.
Dr. Patti Haebe is a results-obsessed naturopathic doctor. She specializes in pre-conception preparation, fertility and hormone optimization. She is committed to root-cause healing through therapeutic supplementation as well as targeted diet and lifestyle modifications. Her virtual practice, Ocotillo Integrative Medicine, provides integrative consultations worldwide via webcam for those looking to incorporate natural, proactive approaches to their healthcare and fertility journey. Schedule a consultation with Dr. Haebe right through your Premom app!