If you haven’t already checked out my blog on the Diagnostic Criteria and Four Types of PCOS, dig into that here. That information is important in setting the stage for this 4 part discussion on The Root Causes of PCOS. My hope is if you understand the root causes of PCOS, you will be well equipped to navigate this lifelong disorder with your healthcare providers at all stages of your life.
When I set out to write this post, I thought it would be a quick review, and just like everything else, PCOS, it quickly became complex, multi-layered, and full of juicy details. So it’s broken up into 4 (relatively 😉 ) bite-sized parts. Happy reading!
PCOS (AKA: Polycystic Ovary Syndrome) is the most common endocrine disorder in reproductive-age women. The WORLDWIDE prevalence is 5-10%. That’s A LOT of women. The association of PCOS with infertility has been well studied and thought to be responsible for up to 40% of female infertility. (Krysiak R, et al. 2006)
Clues that PCOS is Lurking Behind the Scenes
- Anovulation
- not ovulating, not seeing an increase in BBT and/or low progesterone in the luteal phase (second half of your cycle)
- Menstrual irregularity
- cycles <25 or >35 days
- Hyperandrogenism
- acne
- androgenic alopecia (hair loss on the head)
- hirsutism (dark, coarse hair growth on the face, chin, chest, back, and abdomen)
- increased testosterone, DHEAs, androstenedione, or DHT in blood
- Infertility
- Insulin resistance or altered blood sugar
- Obesity
- Increased abdominal adiposity
- Polycystic ovaries on ultrasound
The Most Common Root Causes of PCOS
- Insulin Resistance
- Increased Androgens (Hyperandrogenism)
- Inflammation
- Genetics
Let’s dive in!
1. Insulin Resistance and Blood Sugar Dysregulation
The prevalence of blood sugar dysregulation in women with PCOS is 3x higher than women of similar age without PCOS and 2x higher when compared to women of similar age and weight.
What is Insulin?
Insulin is a hormone released from your pancreas when blood sugar (glucose) increases. Blood sugar goes up when we eat sugar (think pastries, bread, pasta, juice, candy, fruit, starchy vegetables, refined grains) or when we’re stressed (emotionally or physically).
Insulin lowers blood sugar (glucose) by facilitating its movement from the blood into cells so it can be used for energy. If there is extra glucose floating around insulin directs it into short-term storage, within muscles and liver, as glycogen. If there is a constant excess of blood sugar it is packed away in fat cells as a more long-term solution, causing fat cells to increase in size. Yes, you read that right, sugar increases body fat. Insulin also blocks the breakdown of fat stores.
Okay, so the important take-home here is…
INSULIN causes your body to…
- STORE energy (sugar, AKA glucose) as fat and glycogen AND
- BLOCK the breakdown of fat
What is insulin resistance?
Insulin resistance is a state when cells become less sensitive to insulin. Blood sugar goes up because insulin can’t do its job, but the pancreas still responds by spitting out more and more insulin in an attempt to lower your blood sugar and feed your hungry cells.
Whoa! You can imagine this vicious cycle is not your friend. Now you have…
- elevated blood sugar (this keeps the cycle in forward motion)
- elevated insulin (which you’ll see later leads directly to more androgens, inflammation, and anovulation)
- fat stores that are being blocked from breaking down (so it becomes so hard to lose weight)
- serious hunger (because your brain is saying FEED ME)
Your Ovaries remain Sensitive To Insulin even when your other cells are not!
Interestingly, body tissues have differing sensitivity to insulin. So even though other tissues become insulin resistant in PCOS, the pituitary gland and ovaries remain insulin sensitive. As insulin increases over time these important tissues are very affected. The pituitary gland releases more LH and the ovaries produce more testosterone, causing anovulation and contributing to many of the complex symptoms of PCOS, such as elevated androgens.
At least 50% of women with PCOS have varying degrees of insulin resistance.
Signs of Insulin Resistance in Women
- Difficulty losing weight
- Increased abdominal adiposity
- Hyperandrogenism: The ovaries produce excess testosterone (androgens) when exposed to increased levels of insulin.
- acne
- androgenic alopecia (hair loss on the head)
- hirsutism (dark, coarse hair growth on the face, chin, chest, back, and abdomen
- Irregular menstrual cycles: Due to excess androgens from insulin exposure.
- Anovulation: Due to excess androgens from insulin exposure.
- Infertility: Due to excess androgens from insulin exposure.
Is there a way to break the cycle of insulin resistance?
You might be asking, Is there a way to break this cycle? The answer is YES! The cycle is broken when blood sugar is consistently lowered over time. It’s important to consider a holistic, whole-person perspective when working to reduce blood sugar and circulating insulin, and improving insulin sensitivity. Here are some considerations.
Nutrition
- Reducing overall caloric intake by even 300-500 calories per day over 6 months has been shown to restore menstrual regularity, improve ovulation, and decrease hirsutism through a 5% weight loss. (Goodman et al. 2015)
- Lower the overall carbohydrate load of your diet and balance carbs with fat and protein to lower the rate of glucose absorption.
- If you aren’t sure how many carbohydrates or calories you currently consume in a day you could track it for 3 days in a free app like Cronometer.
- Make breakfast your largest meal of the day and dinner your smallest. (Jakubowicz et al. 2013)
- Consider eating in a smaller window of time, such as 9 AM – 6 PM. Insulin sensitivity is inherently worse at night for everyone so pass on night eating.
- Focus on eating non-starchy veggies, nuts & seeds, lots of fiber (mostly from veggies), protein (plant & animal), and healthy fats. Skip the other stuff!
Movement
- Adding movement to your daily routine will improve insulin resistance. The goal is 30 minutes daily, or at least 5 days a week. The research is really showing that even shorter amounts of time, 75 minutes per week, but at a higher intensity is even more effective. A form of exercise known as HIIT – high-intensity interval training.
Strength
- Increase your muscle mass through strength training of any kind.
Mind-Body
- Anything you can do to nourish your spirit and calm your mind will also help to keep your blood sugar balanced.
- Talk therapy with a mental health provider
- Meditation
- Deep breathing
- Nighttime decompression rituals
- Time with friends and loved ones
- Anything that brings you joy
- Journaling
- Creativity
- Laughter
Herbs & Nutrients
- Herbs and nutrients that have been shown to help with blood sugar and insulin resistance:
- Inositol (both myo-inositol & d-chiro inositol) has been shown to increase insulin sensitivity and decrease androgens. (Fromuso, et al. 2015)
- Vitamin D has been shown to improve glucose metabolism in women with insulin resistance. (Jamilian M, et al. 2017)
- Chromium Picolinate is useful to reduce insulin resistance and stimulate ovulation. (Ashoush S, et al. 2016)
- Alpha Lipoic Acid decreases fasting insulin and glucose. (Genazzani AD, et al. 2018)
- Berberine has demonstrated improvements in insulin sensitivity. (Rondanelli M, et al. 2020)
Medications
- Metformin lowers insulin levels
Genetics
Many women are genetically more susceptible to insulin resistance, making them more prone to PCOS. Unfortunately, there is no perfect way to determine this. My point in bringing this up, is that the process of improving glucose tolerance and insulin sensitivity can be more difficult for some women despite their best efforts.
Testing For Insulin Resistance
The following are signs that you may be insulin resistant. The gold standard for detecting insulin resistance is invasive and inaccessible for most people, so here are some alternatives.
- BMI >25
- Online BMI Calculator
- A BMI >25 is not a guarantee of insulin resistance, but there is a greater risk if this is the case.
- BMI 20-24.9 but body composition is such that there is increased mass around the abdomen and waistline
- Many lean (BMI <25) women with PCOS have measurable body composition differences that contribute to insulin resistance, including increased abdominal adiposity.
- Waist to Height Ratio >/=.49+
- Online Waist to Height Ratio Calculator
- The Waist to Height Ratio predicts insulin resistance in 71% of women with PCOS.
- This is preferred over BMI and a great way to track improvements in body composition and likely insulin resistance.
- Normal = .42-.48
- HOMA-IR >2 (Homeostatic Model Assessment for Insulin Resistance)
- Optimal <1.5
- The ratio between Fasting Insulin and Fasting Glucose (blood) to determine the likelihood of insulin resistance
- Oral Glucose Tolerance Test With Insulin (2-4 hour test)
- 75g of glucose is consumed as a liquid after an overnight fast. Glucose and insulin levels are then assessed every 30 minutes to an hour over a 2 to 4 hour period of time. This will provide a dynamic view of response and is the best way to assess insulin resistance without overly invasive testing.
- Dysglycemia is more evident in a 2-hour post-glucose challenge than it is in fasting glucose making fasting glucose tests less accurate on their own. (fasting glucose >/= 100 mg/dl or 2-h post-challenge glucose >/= 140 mg/dl)
- This is my preferred method of testing.
- Continuous Glucose Monitoring
- This is a wearable device that provides constant monitoring of your blood glucose throughout the day and night and the results are transmitted to an electronic device often through an app on your phone.
- This will not provide information about your insulin levels, but it will provide valuable data regarding your blood sugar stability and can be an empowering way of learning how your diet and lifestyle are influencing your blood sugar.
- This is currently a prescription item.
Consider working with a holistically-minded provider who can offer a thorough assessment of your whole health and provide personalized therapeutic options. You don’t have to go this journey alone! 🙂
I always hope that my posts are supportive of your journey. There are additional resources and references below. Leave me a comment, check back often, and reach out if you need a partner in this process! Thanks so much for reading.
If you haven’t done so already, check out my other PCOS Related Blog Posts! Parts 2-4 of this Root Causes of PCOS series will be posted soon.
Disclaimer: This website and post include general information about nutrition, health, and fertility. This content is not medical advice. It is not a replacement for medical advice, diagnosis, or treatment of any health condition or illness. With that said, if the reader or any other person has a medical condition, concern, or illness, they should consult with their personal doctor or another appropriately licensed healthcare provider. The reader should also never disregard professional medical advice or delay in seeking advice because of something discussed in this information. It is imperative to consult your doctor or another appropriately licensed healthcare provider before implementing any changes to your diet, fitness routine, lifestyle, medications, or nutritional supplements.
Information provided in this document and the use of any products or services related to this document by you does not create a doctor-patient relationship between you and Tamara Darragh, ND.
Statements regarding dietary supplements have not been evaluated by the Food and Drug Administration and are not intended to diagnose, treat, cure, or prevent any disease.
Additional Resources
ONLINE SUPPLEMENT DISPENSARY: FULLSCRIPT
Enjoy 15% off!
NATUROPATHIC, INTEGRATIVE & FUNCTIONAL MEDICINE PROVIDERS
If you’re looking for help with PCOS, Integrative Fertility Support or individualized Preconception Health Optimization, and interested in working with me I’m available via virtual consult. Schedule a FREE 15-Minute Discovery Call today! Alternatively, if you would like to find a practitioner in your area, see the resources below.
- Dr. Tamara Darragh
- Minnesota Association of Naturopathic Physicians
- American Association of Naturopathic Physicians
- The Institute for Functional Medicine
FREE FERTILITY GUIDE
Grab your FREE guide: 35 Ways to Optimize Fertility Naturally. Download it today!
LET’S STAY CONNECTED
Sign up for our newsletter to stay updated on new posts, recipes, book reviews, resources, courses, and practice promotions.
Follow Dr. Tamara on Instagram and Facebook!
References
- Ashoush S, Abou-Gamrah A, Bayoumy H, Othman N. Chromium picolinate reduces insulin resistance in polycystic ovary syndrome: Randomized controlled trial. J Obstet Gynaecol Res. 2016 Mar;42(3):279-85.
- Formuso C, Stracquadanio M, Ciotta L. Myo-inositol vs. D-chiro inositol in PCOS treatment. Minerva Ginecol. 2015 Aug;67(4):321-5.
- Genazzani AD, Shefer K, Della Casa D, Prati A, Napolitano A, Manzo A, Despini G, Simoncini T. Modulatory effects of alpha-lipoic acid (ALA) administration on insulin sensitivity in obese PCOS patients. J Endocrinol Invest. 2018 May;41(5):583-590.
- Goodman NF, et al. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS, AMERICAN COLLEGE OF ENDOCRINOLOGY, AND ANDROGEN EXCESS AND PCOS SOCIETY DISEASE STATE CLINICAL REVIEW: GUIDE TO THE BEST PRACTICES IN THE EVALUATION AND TREATMENT OF POLYCYSTIC OVARY SYNDROME–PART 1. Endocr Pract. 2015 Nov; 21(110:1291-300.
- Jakubowicz D, et al. Effects of caloric intake timing on insulin resistance and hyperandrogenism in lean women with polycystic ovary syndrome. Clin Sci (Lond). 2013; 125:423-432.
- Jakubowicz D, et al. High caloric intake at breakfast vs. dinner differentially influences weight loss of overweight and obese women. Obesity (Silver Spring). 2013 Dec; 21(12):2504-12.
- Jamilian M, Foroozanfard F, Rahmani E, Talebi M, Bahmani F, Asemi Z. Effect of Two Different Doses of Vitamin D Supplementation on Metabolic Profiles of Insulin-Resistant Patients with Polycystic Ovary Syndrome. Nutrients. 2017 Nov 24;9(12):1280.
- Khan MJ, et al. Genetic basis of polycystic ovary syndrome (PCOS): Current Perspectives. Appl Clin Genet. 2019 Dec 24; 12:249-260.
- Krysiak R, et al. Update on the management of polycystic ovary syndrome. Pharmacol Rep. 2006; 58:614.
- Qu F, et al. A molecular mechanism underlying ovarian dysfunction of polycystic ovary syndrome: hyperandrogenism induces epigenetic alterations in the granulosa cells. J Mol Med. 2012; 90:911-923.
- Rondanelli M, Infantino V, Riva A, Petrangolini G, Faliva MA, Peroni G, Naso M, Nichetti M, Spadaccini D, Gasparri C, Perna S. Polycystic ovary syndrome management: a review of the possible amazing role of berberine. Arch Gynecol Obstet. 2020 Jan;301(1):53-60.
