A lot of women come to my clinic complaining that they can’t seem to lose weight, no matter what they try. They might have acne that they haven’t experienced since puberty and notice changes in their hair growth as well. One of the diagnoses that I consider in this case is PCOS. It’s important to explore other possibilities in addition, in order to not only seek a correct diagnosis, but get to the root cause of the hormonal imbalances. 

Keep reading to learn:

• What is PCOS and how is it diagnosed?
• What causes PCOS?
• Functional medicine testing for PCOS
• Treatment approaches for PCOS
  

What Is PCOS And How Is It Diagnosed?

Polycystic ovary syndrome (PCOS) is a group of symptoms related to high levels of male hormones that are known as androgens. Hyperandrogenism, or high levels of androgens in women, cause PCOS symptoms including the stimulation of hair growth, acne and male pattern baldness. They affect libido and weight. These high levels of male hormones – produced in the adrenal glands, ovaries and fat cells - are thought to prevent the ovaries from making eggs and producing hormones the way they normally would.  Most women with hyperandrogenism have PCOS. 

“It’s important to explore other possibilities in addition to PCOS in order to not only seek a correct diagnosis, but get to the root cause of the hormonal imbalances.”

There are two different “types” of hyperandrogenism: clinical and biochemical. Either of these can qualify as PCOS. Clinical is visible signs or symptoms indicating androgen production is high, and that can be seen without testing. Biochemical is when labs show high levels of androgens in the blood. It is possible to have clinical signs of hyperandrogenism and for all blood work to come back normal. It is also possible to have labs indicate excess androgens but there be little to no clinical signs. 

The most commonly used diagnostic criteria for PCOS is the Rotterdam criteria. Which indicates that either biochemical or clinical signs of hyperandrogenism qualify. For example, let’s say you have facial hair or male pattern baldness. These are clinical signs of hyperandrogenism. You do not need to have elevated labs to quality for the diagnosis of PCOS. Secondly, according to the Rotterdam criteria, you don’t have to have elevated androgens to be diagnosed with PCOS. 

Specifically, when it comes to androgens, there are two other possible causes of hyperandrogenism that your doctor will want to check for: congenital adrenal hyperplasia and Cushing’s disease. 

Congenital adrenal hyperplasia (CAH) is an inherited disease that results in abnormal functioning of the adrenal glands. Men and women with CAH are missing a vital enzyme that impairs production and regulation of certain hormones. One group of hormones potentially affected are androgens.

Most people born with CAH are diagnosed when they are young, but there is a milder variation of the disease and doesn’t produce obvious symptoms until later in life. This is sometimes known as late-onset CAH or non-classic CAH. The symptoms of non-classic CAH can be very similar to PCOS. Before your doctor can diagnose you with PCOS, non-classic CAH should be ruled out first.

Cushing’s disease is another syndrome that can lead to symptoms similar to PCOS. Cushing’s disease occurs when the body is exposed to high levels of cortisol over an extended period of time. This can happen due to long-term oral steroid use, or it can also occur if the body itself creates the excess cortisol. You should be checked for this, if only to rule it out. 

Cushing’s syndrome may be caused by a non-cancerous tumor on the pituitary gland or adrenal gland. This growth may produce abnormally high levels of an androgen hormone, adrenocorticotropic hormone (ACTH). The excess androgens can be mistaken for PCOS. This is why Cushing’s disease must also be ruled out first.

What Causes PCOS?

Let me explain the hormone piece in greater detail. 

Androgens are precursors (can turn into) to estrogens via what’s known as the steroidogenic pathway. Because of this, excess androgens can be one reason behind estrogen dominance, a condition characterized by a high estrogen to progesterone ratio in the body. Symptoms of estrogen dominance often go hand-in-hand with PCOS and cause symptoms including irritability, sore breasts, water retention, fatigue, PMS, hair loss, infertility and others. Note that lack of ovulation is part of the reason for estrogen dominance. This is because the levels of estrogen remain continuously high, and there is insufficient progesterone to counter these high levels.

What causes PCOS? Causes are thought to be both genetic and environmental. PCOS can even be caused from exposure to androgens and toxins invitro (in the womb before birth). That is different than environmental exposures later in life.

There are many thoughts about why this happens and I’ve cited some interesting resources below for further reading. We’ve talked a little about the relationship with estrogen and there are associations with other female hormones also. One example is gonadotropin-releasing hormone, a hormone in the brain, which can have downstream effects on luteinizing and follicle stimulating hormones, which regulate the female cycle. When these hormones are imbalanced, it affects sex hormones and contributes to symptoms. 

PCOS has close associations with diabetes, insulin resistance, metabolic syndrome, and thyroid disease. Additionally, it appears to be interwoven with many factors in the body and, well, it is very complex! The complexity of hormones is one reason that a functional medicine provider is invaluable for helping with the detective work required to uncover what is going on in your unique body. 

PCOS Testing

These are the tests that I recommend when someone presents with symptoms of hyperandrogenism and PCOS:

• Sex hormone testing: progesterone, estrogen, testosterone. Why? To see what specifically is going on with your hormones.
  

• 2-hour insulin glucose challenge that measures fasting blood glucose and insulin and then measures them again at 1 and 2 hour intervals. Why? Because increased insulin decreases sex hormone-binding globulin, which in turn increases free testosterone, leading to increased estrogen and androgenized symptoms caused by excess estrogen or androgens, or both. Furthermore, sugar handling issues can lead to a vicious cycle because increased androgen levels can further increase insulin levels leading to weight gain, and cholesterol in fat can be converted to estrogen as well].
  

• Total and free blood insulin levels
• Lipid panel
• CBC
• CMP
• Homocysteine
• Ferritin
• CRP
• HgbA1C
• Full thyroid panel (with TSH, free T3, free T4, total T3, total T4, reverse T3, and thyroid antibodies)
• Vitamin D. Why? This helps me to get a complete picture of your metabolism, level of inflammation, nutrient status and other factors that contribute to PCOS symptoms, hormone imbalance and metabolic function. I don’t just treat PCOS, I treat YOU so that you can feel your best and prevent disease! This all matters and needs to be considered in your treatment plan.
• Comprehensive stool analysis with parasitology. Why? The balance and health of the GI tract affects estrogen levels immensely. In addition, hidden gut infections are often a contributor to inflammation. Research is showing us that gut microbiota can cause insulin resistance, hyperandrogenism, chronic inflammation and metabolic syndrome (obesity, diabetes) and there is a correlation in the development of PCOS. As Hippocrates said over 2000 years ago – “All disease begins in the gut.” Looking closely at gut health in order to improve the health and microbial balance of the GI tract helps to balance hormones and improve health throughout the body.

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Testing to rule out: Cushing’s disease, pituitary tumors, thyroid nodules, androgen producing adrenal or ovarian neoplasms, hyperprolactinemia, premature ovarian failure, and congenital adrenal hyperplasia. Why? There are many times that someone is diagnosed with PCOS, when in fact it is not the case. Although PCOS might be the most common diagnosis for a set of symptoms, it is important to rule out other possibilities in order to provide you with the best treatment plan so you can be your healthiest. 

“The complexity of hormones is one reason that a functional medicine provider is invaluable for helping with the detective work required to uncover what is going on in your unique body.”

At The Fork, we try to work within a patients budget for testing and prioritize testing as such. Sometimes we test and sometimes we treat, and sometimes we do both.

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PCOS Treatment

So, what can be done? There are many possible interventions for PCOS to both help heal the root cause and to address the underlying factors that contributed to this syndrome in the first place. Often, I work with both lifestyle factors as well as medical approaches to create a personalized approach for each woman. 

Conventional treatment often involves birth control pills and/or metformin (a diabetes medication); however, I believe it’s not in the patient’s best interest to do this and call it a day. I believe it is safest to start with simple interventions that have the least side effects. Then if necessary, we can implement more aggressive measures. It’s a slow process of fine-tuning what you need. 

Here are some strategies I use in my clinic: 

• Reduce inflammation. I often see in those with PCOS in a state of ongoing underlying inflammation. Inflammation is often chronic and subclinical due to upregulation of macrophages setting the scene and increasing cytokine release. These messengers of inflammation need to be turned off in order to address the underlying causes. We begin doing that with diet and lifestyle modifications. Read Part 2 of my PCOS series (add link) to learn all of the details. 
  

• Consider progesterone. Progesterone treatment can be incredibly beneficial for some women, especially those with low progesterone or estrogen dominance. However, progesterone can be converted to cortisol in those with adrenal issues or whom are under stress. This negates the hopeful balancing effects of the progesterone intended to offset the estrogen dominance. 
  

Some have tried taking pregnenolone, which is a steroid hormone precursor for progesterone. But the problem with any kind of hormone replacement therapies or hormone precursors, such as pregnenolone, is that they are not guaranteed to convert into the hormones your body actually needs. For instance, they can be converted into estrogen downstream and lead to (increased) estrogen dominance as a result of sub-optimal hormone metabolism. Genetic single nucleotide polymorphisms (SNP’s) may also play a role due to effects on enzymes that influence hormone metabolism.

It is complex so it’s important to monitor hormone levels continuously. It is equally as important to know what your body is metabolizing those hormones into. In other words, what your body is making with them. We can tell this by testing hormone metabolites in the urine. In order to know and understand how to best target treatment it is necessary to know where the true issue lies. 

“There are many possible interventions for PCOS to both help heal the root cause and to address the underlying factors that contributed to this syndrome in the first place. Often, I work with both lifestyle factors as well as medical approaches to create a personalized approach for each woman.”

There is a lot that can be done to support a woman with PCOS. The first step is to uncover if it truly is a PCOS diagnosis and what else is going on behind the scenes that is contributing to symptoms and hormone imbalance. I have a lot of functional medicine tools in my toolkit that are integrative and things you can start doing to provide yourself relief today. I talk about many dietary, lifestyle and supplement approaches in Part 2 (link) of this PCOS series. 

PCOS can be a very frustrating condition that feels hopeless sometimes. Having someone in your corner who will not give up on you means so much! Call today to schedule your appointment with me, Chyrl, at The Fork Functional Medicine.

Resources:

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5563096/

Barrett, E. S., & Sobolewski, M. (2014). Polycystic ovary syndrome: do endocrine-disrupting chemicals play a role? Seminars in reproductive medicine, 32(3), 166–176. https://doi.org/10.1055/s-0034-1371088

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4086778/ 

Basu, B. R., Chowdhury, O., & Saha, S. K. (2018). Possible Link Between Stress-related Factors and Altered Body Composition in Women with Polycystic Ovarian Syndrome. Journal of human reproductive sciences, 11(1), 10–18. https://doi.org/10.4103/jhrs.JHRS_78_17

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5892097/

Buliman, A., Tataranu, L. G., Paun, D. L., Mirica, A., & Dumitrache, C. (2016). Cushing's disease: a multidisciplinary overview of the clinical features, diagnosis, and treatment. Journal of medicine and life, 9(1), 12–18.

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Chavarro, J. E., Rich-Edwards, J. W., Rosner, B. A., & Willett, W. C. (2009). Caffeinated and alcoholic beverage intake in relation to ovulatory disorder infertility. Epidemiology (Cambridge, Mass.), 20(3), 374–381. https://doi.org/10.1097/EDE.0b013e31819d68cc

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3071680/ 

Daka, B., Rosen, T., Jansson, P. A., Råstam, L., Larsson, C. A., & Lindblad, U. (2012). Inverse association between serum insulin and sex hormone-binding globulin in a population survey in Sweden. Endocrine connections, 2(1), 18–22. https://doi.org/10.1530/EC-12-0057

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3680959/

Dittrich, R., Kajaia, N., Cupisti, S., Hoffmann, I., Beckmann, M. W., & Mueller, A. (2009). Association of thyroid-stimulating hormone with insulin resistance and androgen parameters in women with PCOS. Reproductive biomedicine online, 19(3), 319–325. https://doi.org/10.1016/s1472-6483(10)60165-4

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