Understanding PCOS: A Comprehensive Guide to Managing Your Health

What is PCOS & How is it Diagnosed?

Polycystic Ovary Syndrome (PCOS) affects around 10% of Australian women, with many more remaining undiagnosed. Many women who have been clinically diagnosed with PCOS report experiencing an uphill struggle to get a diagnosis. In the past, there has been a lack of consensus regarding diagnosis, further complicating treatment. The current diagnostic criteria (known as the Rotterdam criteria) require 2 out of 3 clinical features to be present: 1) Hyperandrogenism, 2) the presence of cysts on the ovaries, and 3) elevated levels of Anti-Mullerian hormone. However, this is a rather simplistic approach to a syndrome that is multifaceted and can have many clinical signs and symptoms.

What Causes PCOS to Develop?

In a nutshell, PCOS can develop as a result of abnormalities in the Hypothalamic-Pituitary-Ovarian-Axis (How’s that one for a word salad!), resulting in an excess of androgens. Androgens are a class of sex hormones mainly associated with male characteristics (an example is testosterone). However, women do naturally have androgens; PCOS is what results when those androgen levels become elevated and interrupt normal ovarian function.

The Hypothalamic-Pituitary-Ovarian-Axis: A Vital Connection

It’s a fancy way of describing the communication line — or hormone feedback loop — between three key parts of your body that work together to control your menstrual cycle, ovulation, and reproductive hormones. The HPO is essentially a workgroup chat between your brain and your ovaries!

The Hypothalamus is a small but very important part of your brain that is responsible for many vital functions in the body, including hormone regulation. The hypothalamus is like the ‘Manager’, constantly monitoring hormone levels. The hypothalamus produces a hormone that is a key player in reproduction - ‘Gonadotropin-Releasing Hormone’ (GnRH). GnRH is like an important message that the hypothalamus sends to the pituitary gland.

The Pituitary Gland is a small pea-sized gland that sits below the hypothalamus. The pituitary gland could be thought of as a courier or messenger. The pituitary gland receives the message (GnRH) from the Hypothalamus. GnRH triggers the pituitary gland to release two key hormones, Luteinising hormone (LH) & Follicle Stimulating Hormone (FSH). You have most likely heard of these hormones multiple times in discussions around PCOS! Quick refresh: LH triggers ovulation and the formation of the corpus luteum, which, in turn, secretes progesterone. FSH initiates the development of follicles and stimulates follicular cells to release oestrogen. The pituitary gland then forwards the message on to the action team – the ovaries!

The Ovaries respond by maturing an egg for ovulation & produce oestrogen & progesterone. The Ovaries also establish a feedback loop, or ‘check-in’, once oestrogen and progesterone levels rise, sending a message back up the line, to the pituitary and hypothalamus to say ‘hey guys, we have sufficient hormones down here’, so the hypothalamus and pituitary ease off with their requests to produce more. Usually, the system keeps everything in balance and ticking along nicely. When the HPO axis is in perfect harmony, our menstrual cycle runs like clockwork, and ovulation occurs when expected.

The HPO Axis simplified!

How PCOS Disrupts the HPO Axis: It’s a Vicious Cycle!

PCOS is like an obnoxious co-worker who never listens to anyone else’s input or follows orders. They basically talk loudly over everyone else, do minimal work, and cause chaos in the team. The Manager (Hypothalamus) feels under pressure and starts sending out erratic signals, releasing quick bursts of GnRH rather than a steady rhythm. The Messenger (pituitary gland) tries hard to make sense of the confusing messages but suffers from ‘information overload’. The messenger responds by overreacting and sending too much LH and too little FSH to *the ovaries (our action team). The ovaries now have no idea what the hell they were supposed to be doing and are focusing on the wrong tasks! Without enough FSH, egg follicles don’t mature properly, and with too much LH, the ovaries make more androgens (like testosterone) – instead of focusing on getting eggs ready for ovulation. In summary, the project (egg follicles) gets started but is never completed; they remain small cysts, and ovulation is disrupted. When ovulation doesn’t eventuate, oestrogen and progesterone levels stay unbalanced. That imbalance feeds back to the manager and messenger (the hypothalamus & pituitary gland), making their communication even more erratic — a hormonal feedback loop that keeps the cycle off-track.

The Role of Insulin in the Development of PCOS

Elevated insulin levels can contribute to the dysfunction of the HPO axis and lead to the development of PCOS. In fact, many women with PCOS have insulin resistance, and it’s not just overweight women; lean women with PCOS are often surprised to discover that they have insulin resistance. Elevated insulin levels wreak havoc on hormones; they can increase hypothalamic GnRH pulse frequency and really mess with the LH: FSH ratio. Insulin and LH work synergistically, meaning they both encourage each other to produce more androgens (such as testosterone). Insulin can also decrease levels of sex hormone-binding globulin (SHBG). SHBG is an important hormone produced primarily by the liver. SHBG plays a key role in hormone regulation; it acts as a buffer, controlling the amount of ‘free hormones’ that circulate in the body to maintain balance. SHBG has a special affinity for testosterone; it binds to free testosterone, taking it out of circulation for immediate use. In PCOS, SHBG levels are decreased, and it can no longer maintain its role as a buffer, meaning testosterone is allowed to run rampant!

Management of PCOS

The International evidence-based guideline for the assessment and management of PCOS states that dietary and lifestyle interventions should be the primary approach for managing the condition. Studies have shown that even a relatively modest 2-5% weight reduction can significantly improve insulin sensitivity, restore ovulation, decrease testosterone levels, and increase SHBG levels. However, many women with PCOS can really struggle with weight loss.

Dietary Recommendations for Managing PCOS, and Why I Don’t Recommend Intermittent Fasting!

When it comes to weight loss with PCOS, slow and steady wins the race. Studies have shown that the best results for managing PCOS are achieved by aiming for slow, sustainable weight loss. 500g per week correlated with positive outcomes. In fact, some studies have shown that rapid weight loss can make the symptoms and hormone dysregulation of PCOS worse. While intermittent fasting is a bit of a buzzword in the diet world that you can’t avoid, long-term studies suggest that the long-term weight loss is at best quite minimal. That’s putting your body into starvation mode and being constantly ‘hangry’ for little to no result. When we skip meals or fast, we put our bodies under stress, which causes cortisol levels to rise and blood sugar levels to spike. These are two scenarios that we really want to avoid with PCOS!

Cortisol and the ‘Progesterone Steal’

Women with PCOS frequently have higher cortisol levels than women without PCOS. Cortisol is essentially the stress hormone, the hormone behind our fight-or-flight response. If you are being chased by dinosaurs, cortisol is your friend, but it can be quite the foe in everyday life. Chronic stress causes the body to prioritise cortisol over progesterone, as both hormones share the same precursor, pregnenolone. This phenomenon is known as ‘progesterone steal’. When we are chronically stressed, the body diverts pregnenolone away from producing progesterone to make more cortisol. In addition to inhibiting progesterone, cortisol also inhibits LH, FSH, and oestrogen. Elevated cortisol suppresses insulin secretion from beta cells in the pancreas, leading to insulin resistance and elevated blood sugar levels. As insulin resistance is a key driver of PCOS and elevated androgen levels, a key target for PCOS management should be to keep blood sugar levels stable. Because insulin is also a fat-storing hormone, fasting may be sabotaging your weight-loss goals.

Dietary Approaches I Recommend for PCOS

• Eat regularly to keep blood sugar levels stable and cortisol levels down.

• A high-protein, moderate-carb diet, focusing on low-GI foods.

• The Mediterranean diet is ideal for PCOS; it has a lot of protein, and it's full of whole grains, vegetables, and legumes. In one clinical study, the Mediterranean diet was superior in restoring ovulation and insulin sensitivity. The Mediterranean diet is anti-inflammatory and has shown promising results in preventing metabolic and cardiac disease.

• Regular exercise – especially resistance training, which has been demonstrated to improve insulin sensitivity.

  
  

Conclusion: Your Journey Towards Hormonal Balance

My name’s Samantha, I’m a naturopath specialising in women’s reproductive health and mental wellness. If you are based in Australia and would like a personalised treatment plan & support for managing PCOS and getting your hormones back on track, you can book an online consult.

Remember, you are not alone in this journey. Together, we can work towards achieving lasting hormonal balance and vitality by addressing the root causes of your health concerns. Let's take this step towards a healthier you!