Published March 24 2014
Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder in females (1), as it affects 5% to 10% of women of reproductive age (2). The condition is characterized by hyperandrogenism, oligomenorrhea or amenorrhea, and polycystic ovaries, and it is associated with significant endocrine, metabolic, cardiovascular, reproductive, and psychiatric morbidities (2). And it is common for women with PCOS to also have a thyroid or autoimmune thyroid condition.
As I briefly mentioned earlier, there are three primary characteristics associated with PCOS. Hyperandrogenism means that there is an excessive amount of androgens, such as testosterone, dihydrotestosterone (DHT), and/or androstenedione. Clinical manifestations of hyperandrogenism include hirsutism (excessive growth of hair), acne, androgenic alopecia (male pattern baldness), and virilization (the development of male characteristics) (3).
Oligomenorrhea or amenorrhea is another characteristic of PCOS. Oligomennorhea refers to infrequent menstruation, while amenorrhea is the absence of a menstrual period. These conditions are due to the hormone imbalance. Elevated circulating androgen levels are observed in 80–90% of women with oligomenorrhea, as elevated levels of free testosterone account for the vast majority of abnormal findings in the laboratory examination (4).
Polycystic ovaries are the third characteristic of PCOS, and this refers to the multiple cysts in the ovaries. However, it’s important to understand that just because a woman has multiple ovarian cysts doesn’t mean she has PCOS. PCOS is usually diagnosed by the presence of at least two out of three of the common characteristics I listed.
In addition to these three common characteristics I mentioned, there are other signs and symptoms commonly associated with PCOS. These include weight gain or obesity, insulin resistance, oily skin, high cholesterol levels, and/or elevated blood pressure.
How Does Someone Develop PCOS?
Just as is the case with many chronic health conditions, many people who develop PCOS do seem to have a genetic predisposition, although the development involves a combination of genetic and environmental factors (5). Recent evidence shows that polymorphisms in the CYP1A1 gene may lead to an increased susceptibility to PCOS (6). However, more research needs to be done in this area.
The Role of Insulin Resistance In PCOS
Numerous studies show that women with PCOS have a high prevalence of insulin resistance (7) (8) (9). The research shows that insulin resistance and the compensatory hyperinsulinemia affects approximately 65–70% of women with PCOS, with 70–80% of obese and 20–25% of lean women exhibiting these characteristics (10). So about 2/3 of women with PCOS have insulin resistance, although some claim that insulin resistance is a factor with EVERY woman who has PCOS. While obesity is also very common, about 20-25% of those who have PCOS are lean. It does seem that most women with PCOS who are obese have insulin resistance, while some lean women with PCOS have normal insulin sensitivity (11).
The insulin resistance is what leads to the increased levels of male hormones in PCOS. P450c17 is the key cytochrome that regulates androgen synthesis, and its regulation is a significant factor in the expression of hyperandrogenism (12). In women with PCOS, the elevated insulin levels stimulate P450c17 activity, and this in turn is what stimulates ovarian androgen production (13). So when a woman with PCOS presents with high androgen levels (i.e. high free testosterone levels) then the primary goal should be to address the insulin resistance. This also should help to resolve the menstruation problems.
I’ve discussed insulin resistance in past articles, as this condition occurs when the body becomes resistant to the effects of insulin. Lifestyle factors play a big role in the development of this condition, so obviously the goal should be to eat a whole foods diet, minimize one’s intake of carbohydrates, exercise regularly, and taking certain supplements can also help in some cases. For more information you can check out my articles “Insulin Resistance and Thyroid Health” and “The Relationship Between Insulin Resistance and Thyroid Weight Gain“.
I did come across an interesting study which looked to determine whether timed caloric intake influences insulin resistance and hyperandrogenism in lean women with PCOS (14). The study showed that eating a high calorie breakfast with a reduced intake at dinner in lean women with PCOS results in improved insulin sensitivity and reduced cytochrome P450c17 activity. This in turn improves both the high levels of androgens, along with the ovulation rate. While this alone probably isn’t going to resolve most cases of insulin resistance, it’s something to consider.
Vitamin D and PCOS
It is common for women with PCOS to be deficient in vitamin D, as 67 to 85% of women with PCOS have 25-hydroxy vitamin D levels that are less than 20 ng/mL (15). This deficiency may play a role in exacerbating PCOS (15). Of course vitamin D deficiency is also common in many other conditions, including those people with thyroid and autoimmune thyroid conditions. I’ve written numerous articles and blog posts about vitamin D in the past, and based on the experience with my patients and the research I have done on vitamin D I feel that everyone should get the serum 25-hydroxy vitamin D test, and should strive to get the levels above 50 ng/mL.
PCOS In Thyroid and Autoimmune Thyroid Conditions
There is a high prevalence of thyroid and autoimmune thyroid conditions in PCOS. Both hyperthyroid and hypothyroid conditions have a direct effect on ovarian function, although autoimmunity may also be involved in this process (16). One study discussed how thyroid dysfunction has been associated with ovarian hyperstimulation syndrome and PCOS (17).
A few studies have demonstrated the higher prevalence of autoimmune thyroid conditions in people with PCOS. One study demonstrated a threefold higher prevalence of autoimmune thyroiditis in people with PCOS, which correlated with an increased estrogen-to-progesterone ratio (18). What this means is that those with PCOS showed normal to high levels of estrogen along with low progesterone levels. The study discussed how people with PCOS have very low levels of progesterone, which counteracts the immune stimulatory activity of estrogen. So perhaps this estrogen dominance condition in PCOS is what triggers an autoimmune response, thus leading to an autoimmune condition such as Hashimoto’s Thyroiditis or Graves’ Disease. Another more recent study looked at the relationship between thyroiditis and PCOS, and concluded that the prevalence of autoimmune thyroiditis, serum TSH, anti-TPO and anti-thyroglobulin positive rate in PCOS patients are all significantly higher than those in control groups (19).
While there seems to be a high correlation between PCOS and Hashimoto’s Thyroiditis, I did come across a study which looked to see if there is an association between PCOS and Graves’ Disease (20). This was a very small study which consisted of only six women who presented with both PCOS and Graves’ Disease. It was mentioned how the combination of PCOS and Graves’ Disease may emphasize the role of autoimmunity in the development of PCOS.
Natural Treatment Solutions For PCOS
In most cases, PCOS can be treated naturally. While drugs such as Metformin are commonly given to help with the high blood sugar levels commonly found in PCOS, this of course isn’t doing anything for the underlying cause of the condition. Plus, Metformin can lead to other problems, such as a vitamin B12 deficiency. As a result, for those people with PCOS the following factors are important:
1. Eat well and exercise regularly. Obviously this is important for everyone, but especially so for those who have PCOS. As I mentioned earlier in this article, in order to correct insulin resistance one needs to eat a whole foods diet, cut out the refined foods and sugars, and minimize their consumption of carbohydrates and high glycemic foods. Although I normally recommend for my patients to consume less than 200 grams of carbohydrates per day, some people with PCOS need to eat less than 100 grams of carbohydrates on a daily basis. Eating healthy fats is also important. However, while eating well and exercising regularly can greatly help many people with PCOS, some will need to look into the other factors mentioned below.
2. Address the inflammation. If you haven’t read my article on insulin resistance and thyroid weight gain I would highly recommend doing so, as in this article I discuss how to address the inflammatory component of insulin resistance. Of course eating a whole foods diet while minimizing the refined foods and sugars will help with inflammation. You want to eat plenty of vegetables, ideally consuming at least five servings per day. Certain nutrient deficiencies such as vitamin D and the omega 3 fatty acids can make someone more susceptible to inflammation, and as a result, such deficiencies need to be addressed.
3. Consider an herbal approach. A combination of the herbs glycyrrhiza glabra root (licorice) and white peony can greatly help with many cases of PCOS. The combination of these two herbs can inhibit the production of testosterone and promote the activity of aromatase (21). Although this might not be a bad thing to do on a temporary basis to help lower the elevated testosterone levels and support the adrenals, it’s still important to look into the other factors I just discussed.
In summary, PCOS is the most common endocrine disorder in females, and many people with thyroid and autoimmune thyroid conditions have PCOS. Insulin resistance is a big factor in most, if not all cases of PCOS. As result, eating well and exercising regular is very important for those with PCOS. However, in most people it is also necessary to do things to help reduce inflammation. And when high testosterone is a factor the herbs licorice and white peony can also be beneficial.