Discover the Best Functional Medicine Approach to PCOS

Discover how to improve your PCOS symptoms - starting now

Research suggests that approximately one in 10 women of reproductive age suffer from polycystic ovary syndrome (PCOS) (1).

PCOS is a complicated endocrine disorder that affects many body systems and is defined by a combination of signs and symptoms.

Functional Medicine PCOS Polycystic Ovary Syndrome

A functional medicine approach to PCOS can offer significant improvement in this condition.

Women with PCOS may present with any of a number of these signs and symptoms.

Because of this, in our experience, PCOS is one of the most under-diagnosed conditions we come across in our clinic.

Table of Contents

PCOS: undiagnosed epidemic?

Very often in our functional medicine clinics, we find we are working with women who don’t know they have PCOS, but who come to us because they have another, associated health problem.

Often, our clients come to us because they want to restore their menstrual cycle, improve their fertility situation, or improve acne, and upon further investigation, it becomes apparent that these are actually signs and symptoms of PCOS.

In fact, one statistical report estimated that 50-75% of women with PCOS, are unaware that they have this syndrome (2).

It is difficult to know exactly what the prevalence of PCOS is due to differences in diagnostic criteria.

Some studies report the incidence to be 1.6% (5), whilst other more recent reports suggest that almost 20% (6) of the population are affected, making it the most common endocrine disorder in women of reproductive age.

Many people also believe that women with PCOS are always overweight.

It’s true that issues with insulin are a common causal factor of PCOS, and that insulin resistance is frequently associated with obesity.

But this isn’t always the case, it is possible to have insulin resistance and be of normal body weight.

In fact, only between 40% and 80% of those with PCOS are overweight or obese (3).

This means that many women with PCOS have a normal BMI or are lean.

What is PCOS?

PCOS is a common, complex endocrine (hormone system) condition that affects a large number of women in their reproductive years. 

It’s a syndrome, so rather than being a single diagnosable condition – like Type II Diabetes or cancer, it’s a collection of symptoms that together lead to a diagnosis.

It affects many body systems, including:

Higher androgen hormones (the hallmark feature of PCOS) are often noted in blood tests.

The androgen hormones tested are:

These high androgen levels cause symptoms of hirsutism (excessive hair growth on the face, neck, chest, stomach, lower back, buttocks, or thighs), acne and hair loss.

Excess androgens can also reduce ovulation (see the section on fertility below, or our full article on fertility here).

Dysregulated pituitary hormones can also cause issues in PCOS.

In PCOS, usually the pituitary gland hormone, Leutenising Hormone (LH) is elevated, while Follicle Stimulating Hormone (FSH) is low. 

Higher LH stimulates ovarian androgen hormone production, and the relatively lower FSH impairs ovarian follicle development (7) affecting ovulation.

In women, not all the androgen hormones are produced in the ovaries, some androgenic hormones are also produced in the adrenal glands (8).

PCOS diagnosis

In conventional medicine, PCOS is diagnosed when other causes are ruled out and any two of the below three criteria are met:  

With a functional medicine approach to PCOS, the diagnostic criteria aren’t as rigid, and we’re free to base our treatment protocol based on an evaluation of the signs and symptoms presented.

PCOS symptoms

As discussed above, in our experience, PCOS is one of the most under-diagnosed conditions.

Often, we have clients who are working with us to resolve individual symptoms, who are unaware that the symptoms are interrelated, and part of PCOS.

Most women experience one or more of the following signs and symptoms of PCOS:

PCOS Symptoms Infographic Girl with Various Symptoms

Women with PCOS may display all of the classic symptoms, or just a few of them. 

A functional medicine approach to PCOS looks to identify all signs and symptoms, rather than just focusing on the above three criteria.

This helps to design a protocol that is more likely to deliver sustainable and significant benefits to the individual.

What causes PCOS?

In this multi-system, complex disorder, there can be many causes of PCOS.

In some cases the underlying driver for PCOS might be insulin resistance, but in other cases, it could be more of a consequence of adrenal (stress) hormone imbalances.

There is likely more than one factor driving PCOS in each individual case.

This is why, in a functional medicine approach to PCOS, a thorough analysis of causal factors in each case is critical when designing an effective protocol.

The team at Coho assess:

to understand what factors could have initiated the insulin and/or hormonal dysregulation that exists in PCOS.

There is also a strong hereditary link in PCOS, and multiple genes are believed to be involved (4).

As with many inherited disorders, the genetic variations passed to a family member are ‘switched on’ by environmental factors, initiating the changes that then manifest as PCOS.

As well genetics, insulin resistance and stress, other factors that can contribute to the development of PCOS include:

PCOS is characterised by numerous imbalances in physiological mechanisms.

Understanding these systems and imbalances can help us to understand exactly how nutrition, lifestyle, and a functional medicine approach to PCOS can help to improve both those individual symptoms, and overall quality of life.

The conventional medicine approach to PCOS

The conventional medical approach to PCOS is to treat the signs and symptoms (but not the root causes) with medication. 

To regulate the menstrual cycle, doctors may prescribe oral contraceptive pills (combined or progesterone only).

To help you ovulate, metformin (a diabetic medication) may be prescribed or medications such as clomiphene or letrozole.

To reduce excessive hair growth, birth control pills or androgen reducing medications such as spironolactone may be prescribed.

Whilst these medications may provide symptomatic relief, they all come with side effects, and none address the underlying causes of the hormonal imbalances.

A Nutritional Therapy and Functional Medicine approach to PCOS can improve the quality of life for many women by reducing the severity of the symptoms, whilst also correcting the underlying imbalances.

We’re often asked ‘what is the best diet for PCOS’ (or for any other condition)

Because no two women are the same, and because PCOS presents differently in each case, there is no single diet that will help all women with PCOS. 

Below we’ll cover a lot more about how nutritional strategies can aid PCOS, and which nutrition and lifestyle interventions may be right for you. 

Factors associated with PCOS

With a functional medicine approach to PCOS, we take a holistic view of the factors involved. 

This gives us a more complete picture when working with our clients, and in our clinical experience, leads to better outcomes.

Insulin resistance

Insulin resistance is a dysfunction in the ability of cells in the body to respond to the hormone insulin.

Insulin transports glucose (blood sugar) from the blood to the cells, where it’s used to produce energy.

If the cells are not responsive to insulin, glucose stays in the bloodstream, causing high blood sugar (hyperglycaemia).

Uncontrolled, chronic high blood sugar causes insulin resistance, as well as inflammatory responses in the body, that often lead to a host of negative health effects.

In PCOS, about 50 percent of women present with some degree of insulin resistance.

Insulin resistance can occur independent of the extent of obesity.

Even lean women with PCOS can have insulin resistance (and increasing body mass index exacerbates the insulin resistance).

Normal weight adolescent girls with PCOS also have insulin resistance (and are noted to have increased liver fat and muscle mitochondrial dysfunction).

While the presence of some level of androgen hormones is normal and desirable in females, women with PCOS often have high androgen hormones, as a result of having elevated insulin levels.

This is because high insulin levels increase the activity of enzymes in the ovaries that produce androgens.

As you can see, if you want to control and re-balance the levels of androgen hormones in cases of PCOS, you first have to control insulin!

In conventional medicine, metformin (a diabetes medication), is often used to control insulin in PCOS, and is now part of the standard treatment for PCOS.​

Metformin helps to re-sensitise cells to the presence of insulin.

Digestive system dysfunction

Many studies have demonstrated an unbalanced digestive system microbiome and dysbiosis in women with PCOS (9).

Imbalanced digestive system bacteria can affect levels of short chain fatty acids which may increase the amount of energy (particularly from carbohydrates) that the intestinal system absorbs.  

Absorbing more carbohydrates means elevated blood sugar levels, and elevated blood sugar levels mean increased insulin.

Gut bacteria levels are important for healthy oestrogen levels in PCOS. In some PCOS cases oestrogen is high, in some cases, oestrogen is too low. 

Gut bacteria modulates an enzyme called beta glucuronidase which is involved in oestrogen detoxification.

Lower levels of this enzyme have been found in PCOS patients, and these lower levels may contribute to reduced levels of oestrogen.

Improving gut bacteria levels can improve levels of oestrogen.

Oestrogen deficiency can impair menstrual cycles and ovulation.

As we’ll discuss in a second, inflammation is a key physiological driver in PCOS.

Poor gut health is a known driver of systemic inflammation.

Gram-negative bacteria can produce lipopolysaccharides (LPS) that promote systemic inflammation and imbalanced gut bacteria.

Stress and food reactions can also contribute to increased intestinal permeability (leaky gut), which can also drive systemic inflammation.

Inflammation

Chronic inflammation is a common factor that contributes to the pathological features of PCOS. 

Studies have shown higher levels of inflammatory markers in PCOS:

This chronic inflammation can further exacerbate obesity and cause higher insulin levels. 

Drivers of inflammation include:

Increased fat around the middle (visceral adiposity) has not only been associated with insulin resistance, but also with low grade chronic inflammation (11).

Just a 5-10% weight loss in overweight women, over a 6 month period, can improve clinical outcomes in PCOS (12).

Chronic stress & adrenal PCOS

As we discussed earlier, androgens are not only produced in the ovaries, but are also produced in the adrenal glands.  

The adrenal glands produce stress hormones (cortisol, norepinephrine and epinephrine) and also produce the androgen hormones DHEA, androstenedione and testosterone (13). 

An increased stress response from the brain (the HPA axis) can trigger the release of more androgens (and stress hormones) from the adrenal glands.

In fact, it has been suggested that between 20 and 30% of patients with PCOS have adrenal androgen excess (14).

This is called ‘adrenal PCOS’.

PCOS can develop because of chronic stress, and chronic stress can also make PCOS worse in those who already have it. 

Increased stress hormones can also increase insulin resistance, which as we’ve already mentioned, is not helpful in PCOS.

This highlights that stress reduction techniques and lifestyle choices could be significant in supporting the reduction of PCOS symptoms.

Stress management forms a central aspect of the functional medicine approach to PCOS.

Environmental toxins & PCOS

Evidence suggests that exposure to environmental toxins may play a significant role in the development of PCOS. 

Chemicals are ubiquitous in our modern day environment, and these have been associated with many endocrine disorders.

Chemicals in food, air, water, pesticides, plastics, personal care products and other consumer goods are of particular concern to women who are genetically susceptible to developing PCOS (15).

Many environmental toxins act as hormone disruptors in the body.

These toxins can bind to hormone receptors in the body, ‘mimicking’ the effects of naturally produced hormones, and disrupting hormone balance.

BPA and phthalates are two hormone disrupting chemicals that are present in many products and pesticides, and which have been associated with PCOS. 

Higher levels of BPA (16) and higher levels of perfluorinated chemicals (used as repellents in carpets, clothing, in cooking utensils and non-stick coatings) (17) have also been found in women with PCOS.

Exercise

Regular exercise has been shown to improve BMI, insulin resistance and ovulation in PCOS (18).

But excessive exercise (overtraining) can further exacerbate any already imbalanced hormone levels, and through an increased stress response (exercise, even though beneficial, is a stressor and provokes the release of cortisol), further increase androgen levels and increase risk of anovulation.

The Coho functional medicine approach to PCOS

In a personalised, functional medicine approach to PCOS, understanding all possible underlying imbalances, helps to inform an appropriate and highly individualised plan, that would include bespoke nutritional, lifestyle and supplemental support.

Any functional medicine approach to improving PCOS means identifying and addressing root cause factors.

At Coho Health, we follow a process to treat PCOS through:

Specifically targeting areas of imbalances, such as;

Eat a healthy well-balanced diet and increase antioxidants

To help optimise insulin sensitivity, it is usually necessary to:

An anti-inflammatory diet provides a good starting point for women with PCOS who want to modify their diet.

Eliminating refined carbohydrates is a good first step – refined carbohydrates (breads, pastries, biscuits, any other flour based products) are a problem when it comes to insulin.

They cause blood sugar imbalances that can negatively affect inflammation and disrupt the microbiome.

Consuming whole, nutrient-dense carbohydrates such as sweet potatoes, cooked carrots, squash and yam are much better options.

We often find that our clients are not consuming optimal amounts of above ground, fibrous vegetables.

These include vegetables such as:

Including an array of different coloured vegetables daily helps to take in a wide range of health promoting phyto-nutrients and plenty of fibre.

Foods that contain fibre help maintain intestinal health, regulate hormone balance, and provide anti-inflammatory and insulin-sensitising properties.

The ‘right’ dietary fats not only support insulin sensitivity but also exert anti-inflammatory actions.

Include omega 3 fatty acids from wild caught oily fish, flaxseeds, algae, and walnuts or consider a high quality fish oil.

Trans fats should be avoided. These are oils that are found in margarine, fried foods, or overheated oils, and contribute to inflammation.

Include healthy fats such as:

These fats are beneficial in reducing inflammation, aiding in the production of hormones, and promoting hormone balance.

Specific foods and nutrients that help with PCOS

What foods and nutrients can help women with PCOS? 

There are some healthy foods and nutrients that may help women with PCOS feel and function at their best by addressing the underlying imbalances at play.

Berberine, magnesium, alpha lipoic acid can help improve insulin sensitivity, whilst the latter also provides antioxidant support.

Vitamin D can also help improve insulin sensitivity, and may be of benefit in reducing androgen levels (19).

Zinc has been shown to improve insulin signalling, and reduce 5-alpha reductase enzyme activity, lowering the dihydrotestosterone implicated in hair loss.​

Cruciferous vegetables (broccoli, cabbage, cauliflower, kale, turnip, bok choy, watercress) contain several beneficial compounds that assist healthy hormone balance and gut microbiome health, from sulforaphanes, to di-indole methane and calcium d-glucurate.

We often recommend a good quality organic, decaffeinated green tea that can have a number of beneficial effects – supporting insulin sensitivity, providing antioxidant support, and inhibiting inflammation.

There is a great deal of research available in the therapeutic benefit of myo-inositol in PCOS.

Myo-inositol is a naturally occurring substance (one of the nine inositols) frequently considered a part of the B vitamin family.

Studies have demonstrated improved rates of ovulation with myo-inositol supplementation and it is also believed to improve egg quality.

Myo-inositol meditates glucose uptake, improving blood sugar management and also supports Follicle-Stimulating Hormone (FSH) signalling (20).

High concentrations of myo-inositol inside ovarian cells is thought to support the role of FSH, and PCOS patients may have reduced levels of ovarian myo-inositol.

Supporting the microbiome

Supporting the microbiome with prebiotic and probiotic rich foods can support:

Some great foods to include are:

To increase beneficial bacteria, kombucha, kefir, sauerkraut and kimchi are great options when they have been produced by a natural fermentation process.

Polyphenol rich foods support a healthy microbiome – pomegranate, cherries, blackberries, blueberries, green tea, shitake mushrooms, oyster mushrooms and organic cacao powder.

Ketogenic diet

While many whole-food based diets have shown benefits in PCOS, such as:

a higher fat diet, may be one of the best diets for women with PCOS.

However, it’s important to note that the best diet for each person is likely to be different (even to the degree of considering ‘how much more’ fat is best).

In reality a higher fat diet doesn’t necessarily mean a ketogenic diet in each case.

It could be that we’re just reducing the carbohydrates slightly, and having a slightly higher proportion of calories coming from healthy fats, rather than ‘going keto’.

A higher fat / ketogenic diet has been successfully applied in metabolic syndrome and diabetes, with excellent results.

The mechanism of action in PCOS is the same – this type of diet improves insulin sensitivity and weight loss.  

A ketogenic diet is not appropriate in all cases.

For example it may not be appropriate for PCOS in women who are already lean, or in women with high stress (adrenal PCOS type), or if calories are already being restricted.

Please always work with a practitioner before embarking on significant dietary changes.

In our experience, a ketogenic diet often comes at the expense of insufficient fibrous vegetables, so just a note to stay focused on nutrient density, and to maximise intake of above ground vegetables (whilst still keeping overall carbohydrate intake relatively low).

Protein intake

Ensuring optimal protein in PCOS is important for:

You can minimise your exposure to endocrine (hormone) disrupting chemicals by prioritising animal produce that is organically sourced and growth hormone / antibiotic free. 

Dairy products such as yoghurt and cheese are good sources of protein, however as dairy can significantly increase IGF-1 (Insulin-like Growth Factor 1) levels in humans, and in turn increase levels of androgens (22), it is usually recommended to avoid dairy foods in PCOS.

Limit Your Exposure to Toxins in Food and Drinking Water

As we discuss above, environmental chemicals are big endocrine disrupters.

They can cause disturbances in hormone levels and communication, as well as causing metabolic changes.

This is likely through increased inflammation and oxidative stress.

Going plastic free is one of best ways of immediately reducing environmental chemicals (not just removing BPA, but all plastics).  

Going organic means you’re avoiding growth hormones, antibiotics, pesticides and herbicides.

If budget (or availability) doesn’t permit you to go 100% organic, then try to prioritise animal products and the ‘Dirty Dozen’ list of plant based foods (check out the Environmental Working Group, Dirty Dozen list, or for those in the UK, the PAN-UK list)

https://www.ewg.org/foodnews/dirty-dozen.php

https://www.pan-uk.org/dirty-dozen/

Filter your drinking and cooking water to remove endocrine disrupters commonly found in water.

Much better still is to invest in a filter, and filter tap water, than buy plastic bottled water.

Fertility & PCOS

PCOS is a leading cause of infertility in women.

Some women with this condition have pearl-sized cysts or follicles that can be seen on ultrasound scans. 

Eggs from the ovaries are released each month during the ovulation phase of the menstrual cycle.

The eggs are in tiny sacs called follicles that fill up with fluid as the eggs mature.

Each cycle, the most mature follicle breaks open to release a mature egg which may be fertilised.

Due to hormonal changes that occur in women with PCOS, the eggs do not fully mature.

PCOS infographic showing the difference between healthy and poly cystic ovaries

The follicles grow and build up fluid, but the follicles don’t rupture and release the egg(s), and so there in no ovulation.

The follicles then become dormant and are seen as cysts on a scan

PCOS infographic showing the difference between healthy and poly cystic ovaries

Not all PCOS cases have ‘cysts’, some cases of PCOS are diagnosed based on other criteria (such as high androgens and irregular menstrual cycles) (6).

PCOS is a condition associated with higher levels of androgens.

Commonly, androgens are considered to be male hormones.

However, they are actually a group of sex hormones made in males and females, but in different amounts in each sex.

Men generally make more androgen hormones than women.

This group of sex hormones help to start puberty and play a role in reproductive health and body development.

Testosterone is the most common androgen.

In women, androgens can cause more follicles to develop in the ovaries.

But this is not healthy growth, and makes fertility more difficult to manage, even in an IVF setting.

To recap a key point from earlier in the article: one of the key drivers for the increased androgen levels in PCOS, is insulin.

The only meaningful way to manage insulin resistance is through nutrition and lifestyle interventions. 

As you can see, a number of body systems are interlinked, and this is fundamental to the functional medicine approach to PCOS (and many other health challenges!).

And in cases where there is a strong hereditary association with insulin resistance or type 2 diabetes, then supplemental support can be particularly effective in our experience.

PCOS can present itself in different ways.

It doesn’t have to present in the classical pearl-like cyst formation on ovaries that can be seen on an ultrasound.

Remember: high androgens alone can suggest PCOS.

Since PCOS is also associated with inflammation, and the syndrome can affect ovarian reserve (the number and quality of eggs) and egg implantation.

Consistent nutritional and lifestyle interventions can help to turn the hormonal and metabolic (blood sugar regulation) changes around, and thereby improve both natural fertility and IVF success rates.

With a functional medicine approach to PCOS, optimising gut health can also positively influence the condition – a healthy microbiome can improve insulin, inflammation, and hormonal changes.

Book your free 15 minute Discovery Call with Dee Brereton-Patel now

The wrap

With the number of different drivers of PCOS, the systems involved, and the spectrum of symptoms that can be experienced, PCOS is a complex condition that can have far reaching health consequences.

Conventional medicine isn’t great at diagnosing PCOS, and when it does, due to the amount of time it takes to reach a diagnosis, PCOS tends to have developed quite significantly.

Added to that, the medications prescribed for PCOS aim to manage the symptoms, rather than to address the root cause.

We think you deserve better.

PCOS is also significantly under-diagnosed, and in our clinical experience, we often identify PCOS when our clients come to us for help with one of the symptoms – for instance infertility or skin problems.

This condition can be helped through a functional medicine approach to PCOS, and our clients achieve life changing results.

But it requires some really hard work and dedication, as the nutrition and lifestyle changes required can be tough!

To your optimised, healthy future,

Dee & the Coho Health team

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6360964/

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