It’s Sunday night and my husband is plucking the hairs from my chin and “sideburn” area. It’s a ritual that we repeat at least every other week. It’s something I have dealt with for over two decades. When I was diagnosed with Polycystic Ovarian Syndrome in my early 20’s, my doctor filled me in that my “old lady whiskers” had nothing to do with my age and everything to do with my hormones.
At the time of my diagnosis, I had experienced a year of irregular periods. One month I would get it and the next I would not. I even had the joy of having a bleed for a full month. My weight ballooned up to 215lbs. I was the heaviest I had ever been and no amount of calorie counting and exercise would make that number budge on the scale. On the months that I actually had my period, I also had painful cystic acne all over my chin. I felt depressed and anxious. I even had occasional anxiety attacks. This is life with PCOS.
My doctor at the time offered me two solutions. He wanted to put me on birth control pills to “regulate” my cycles. He also wanted to put me on a weight loss drug to help bring my weight down. It worked but the birth control pills contributed to the depression and anxiety symptoms which then had to be masked with benzodiazepines. The weight loss drug that I was on long enough to bring my weight down to 165 lbs left me with a rapid heart rate and the weight crept back on only a few years later. This same doctor also counseled me that if I waited until my 30’s to try to conceive that I might never have children of my own.
We started trying when I was 31. I had realistic expectations. After all, I knew it might be hard for us because I had PCOS. By that time, I had spent the last few years figuring out how to manage my cycles with a diet that was free from gluten and dairy. There was still a lot of variation in my cycle length which meant pinpointing ovulation was tricky. I tried ovulation predictor kits (OPK) and found that I would get a positive around day 6-7 and it would stay positive for many days after. This meant that using an OPK wasn’t an effective way to see if I was ovulating (more on this later).
At 33, I was frustrated! I said something to my OB and next thing you know we were at an appointment with a reproductive endocrinologist. Her first course of action was to put me on Clomid and have us try at home. Then we did three rounds of IUI with a stimulating medication called gonal F. We also did a trigger shot to insure ovulation. My doctor didn’t seem concerned about my history with PCOS and recommended we move forward with IVF. I’m sure I would have gotten pregnant faster if we had continued but I just didn’t want to go that route. I wanted to get a better handle on my PCOS.
At the age of 35, I finally got my first positive that stayed positive. My cycles were regular. My weight was at a good place and I exercised regularly. I worked with an amazing acupuncturist to get on the right supplements and herbs. This ultimately inspired me to specialize in women’s health (but that’s a story for another day).
With September being PCOS Awareness month, I wanted to share some things with you to help you get a handle on your PCOS. These are all things that I wish I had known back when I was diagnosed and back when we first started trying to conceive. We will take a look at the diagnostic criteria for PCOS. Let’s take a look at why using ovulation predictor kits and basal body temperature charting might not be a great way to pinpoint ovulation. Most importantly, I want to give you some of the tools that have made my life with PCOS much easier and ultimately helped me to conceive. These are all things that I wish I had known in my early 20’s and when we were trying to build our family.
What is PCOS? How do I know if I have it?
Polycystic Ovary Syndrome or PCOS is a complex endocrine disorder that is underdiagnosed and affects approximately 5 million women of reproductive age in the United States alone. PCOS accounts for more than 90% of ovulatory disorders and 75% of all cases of anovulatory infertility. Current research is even showing a genetic component. With 1 in 8 couples struggling to conceive, PCOS is sure to be a contributing factor and needs to be taken seriously.
Polycystic Ovarian Syndrome is a syndrome which means a collection of signs and symptoms are needed to make a diagnosis. PCOS can look different for each person.
In 2003, the Rotterdam criteria set 3 standards for PCOS diagnosis. In order to be diagnosed with PCOS, you must meet 2 out of the 3 criteria.
- High Androgens or Androgenic Signs (excess facial and/or body hair)
- Irregular Periods or Delayed Ovulation (cycles that are longer than 35 days in length)
- Polycystic Ovaries on Ultrasound
Let’s take a look at each of these criteria:
- High Androgens or Androgenic Signs
Androgens are typically thought of as “male” hormones. However, both men and women have them. It’s just that men have higher levels. Many women with PCOS may have high androgens. Elevated levels of Testosterone, Free Testosterone, Androstenidione, and DHEA are also common in women with PCOS. However, you can have androgenic signs and not have high androgens. My “old lady whiskers” are better known as male pattern hair growth or hirsutism. You may have hair growth on your chin, nipples, mustache line, or belly. Thinning hair or male pattern balding is very common. Acne is another androgenic symptom. Women with PCOS often have painful cystic acne that is under the surface of the skin.
2. Irregular Periods or Delayed Ovulation
A regular cycle length should be between 25 and 35 days. Women with PCOS may have cycles that are over 35 days in length suggesting delayed ovulation.
3. Polycystic Ovaries on Ultrasound
Due to the hormonal imbalances associated with PCOS, eggs may not mature properly or be released at all during ovulation. When anovulatory cycles like this happen, follicles can collect on the ovaries as small immature cysts. This leads to the “ring of pearls” on ultrasound that many associate with classic PCOS. To meet this criteria, you would have to have at least 12 cysts.
Diagnostic Tests for PCOS
The following lab tests can help give you and your doctor some added insight into how PCOS is affecting your body. It may even help get you an accurate diagnosis. The ranges given below may be different depending upon the lab that your provider uses, etc. Please consult with your doctor as to what these tests tell you about managing your overall health.
- Day 3 Labs for FSH, LH, Estradiol, Progesterone and Prolactin: This blood work is run on the third day of your menstrual cycle. In women with PCOS, the ratio between FSH and LH will usually show that LH is higher.
- AMH: This particular test is used to determine ovarian reserve. For the average individual, we are looking for a level between 1 and 4 . It’s common for women with PCOS to have an AMH over 4.
- Pelvic Ultrasound: Once again, this is looking for cysts on the ovaries.
- Vitamin D: Between 40 and 60 ng/mL is considered the most ideal. Vitamin D has been shown to be helpful for fertility. It also has some influence on metabolism, especially in regards to PCOS and insulin resistance.
At its root, PCOS is a metabolic disorder. This is characterized by high blood sugar and insulin resistant cells. When cells are insulin resistant, they can’t properly take glucose from the bloodstream which is what insulin signals them to do. Women with PCOS often struggle to lose weight and there is an additional inflammatory response that comes from fatty tissue. Even when they are lean, women with PCOS have difficulty with sugar and have an inflammatory response to dips and spikes in blood sugar. For this reason, one of the first lines of defense when you reach out to your doctor is metformin. Metformin is typically used to treat Type II Diabetes. Although metformin is readily available, many women with PCOS find that they can manage blood sugar better utilizing diet, exercise, and acupuncture without the side effects of metformin. The following tests may help you and your doctor determine your level of metabolic syndrome:
- Fasting lipid profile: In women with PCOS this usually shows elevated cholesterol, elevated triglycerides, elevated LDL, low HDL, and low apolipoprotein A-1
- Fasting Insulin: normal range should be between 75-95 mg/Dl
- A1C looks at the average blood sugar over the past 2-3 months. Normal A1C should be 5.6 percent or below.
- Insulin Resistance Testing (HOMA IR). The HOMA IR looks at the relationship between insulin and glucose. This ratio ideally would be under 1.
Why won’t Basal Body Temperature charting and ovulation predictor kits work well to predict ovulation in women with PCOS?
At the beginning of the menstrual cycle, our pituitary gland secretes a hormone called follicle stimulating hormone or FSH. FSH makes several follicles grow in the ovaries usually over the first 3-4 days of our cycles. These follicles secrete estrogen which ideally keeps our waking temps averaging around 97.2. The estrogen helps to thicken the lining of the uterus. When estrogen reaches its peak, the pituitary gland releases lutenizing hormone. The high level of estrogen combined with the rising level of lutenizing hormone causes the dominant follicle to swell and break open or lutenize, releasing the egg. Many women experience a dip in temperature at this time, indicating ovulation has occurred.The follicle then morphs into a temporary gland called the corpus luteum that pumps out progesterone and raises our waking temps to an average of 98.2.
An ovulatory chart looks something like this:
For many women, BBT charting can give them a window into the picture of estrogen and progesterone in their bodies and help them to plan sex in their fertile window but this isn’t the case for those of us with PCOS. During an anovulatory cycle, the temperatures stay relatively steady throughout the month instead of showing the biphasic pattern that’s indicative of ovulation. Anovulatory cycles and/or long cycles, even if only periodic, can be frustrating and lead to delays in conception.
Example of Anovulatory Chart:
Ovulation Predictor Kits work to predict ovulation by detect lutenizing hormone in the urine. The release of Lutenizing hormone is meant to trigger ovulation which in turn would trigger a rise in BBT temperatures. A rise in temperature confirms ovulation has occurred, but this process doesn’t always go smoothly in women with PCOS. Normally, Lutenizing Hormone would be released in one burst, only detectable over a 24 hour period of time, but with anovulatory cycles ovulation predictor kits may show lutenizing hormone spikes earlier and/or lingering for many days in a row. This makes it difficult to predict ovulation and plan baby making sex. In the end it can leave women with PCOS questioning when or whether or not they’ve ovulated.
Managing PCOS to Optimize Ovulation and Regulate Menstruation and Support Fertility
As I said before, PCOS is a syndrome and can look very different for everyone. Your path to regular menstruation and ovulation might not be a straight line but the following tools are a great place to start. Ultimately, we want monthly periods with a consistent cycle length of 35 days or less. As you work through the suggestions below, you should see your BBT charts show a luteal phase (second half of your cycle) rise in temperature to an average of 98.2. Each time you see a rise in temperature which stays above 98 degrees, you know you’ve ovulated. BBT charts may not help you predict ovulation in the beginning, but they can confirm when ovulation has occurred (retroactively) and they can help you track progress when working to stabilize hormones, manage PCOS and make decisions about how to proceed with baby making interventions. As an added bonus, you may notice your hair thickening, less male pattern hair growth, and clearer skin.
Eating for PCOS
A diet that is rich in dark green leafy vegetables, clean hormone free organic meats, and the right carbohydrates is the way to go. Avoiding dairy, gluten, and sugar is extremely helpful as these foods are inflammatory in nature. We can’t control everything we come in contact with on a daily basis, but we can control what we put into and on our bodies.
In general, women with PCOS do well with a protein portion about the size of their hand at each meal. Most of the meal should consist of colorful vegetables. Add healthy fats like avocado, olive oil, coconut oil, etc. Fats are wonderful for their ability to slow elevations in blood sugar while not raising insulin. Carbohydrates should be customized to the individual. Each meal should contain a cupped hand portion of carbohydrates like squash or sweet potatoes. The Glycemic and Insulin Index can provide guidance on which carbohydrate will impact blood sugar as well as insulin levels the most (or least). For the more athletic individual with PCOS, you may find that your body needs an additional carbohydrate portion with each meal.
I have to add one more little thing about carbohydrates. Some women with PCOS will need to maintain extremely low carbohydrate and very high fat diets to manage symptoms. This is why we often hear that a ketogenic diet that consists of high fats, moderate protein levels, and very low carbohydrates works well for PCOS. I personally fall into this category. I know how it seems impossible to live without fruit, grains, potatoes but the benefits are well worth it for women with severe insulin resistance. I can honestly say that when I stick to a more ketogenic diet, it is easier for me to maintain a balanced weight and a more balanced energy level.
If you are overweight (not everyone with PCOS is overweight), shoot for a weight loss goal of just 10 pounds. That ten pounds can get you underway to better ovulation and regular menstruation.
That being said, losing weight with PCOS can be a real challenge! If weight loss is particularly hard for you, intermittent fasting/ time restricted eating may give you a jump start. Intermittent fasting is when you have an eating window of about 10 hours with a “fasting” window of 14 hours. This way of eating can help resensitize insulin receptors.
Moderate daily exercise such as walking for 30 minutes can help further regulate blood sugar levels and happy blood sugar is key for most folks with PCOS. Exercise helps to take glucose out of the blood stream for use by your muscles. The effects can be felt for up to 24 hours after working out.
Resistance training 3 times a week has been shown to reduce androgens (those pesky hormones that cause the acne, hirsutism, and male pattern hair loss many women with PCOS experience). If you really don’t have the time to dedicate to exercise, then high intensity interval training (HIIT) may be the way to go for you. 75 minutes of vigorous exercise per week beats out moderate exercise at 150 minutes per week as to the great effects of exercise on metabolic parameters. Look for a HIIT or Tabata class at your local gym.
Supplements were a real game changer for me. As soon as I started taking NAC, I noticed my skin was clearer! Inositol made me feel less anxious and left me wondering where it had been my whole life!
Supplement quality matters. Reach out to us or a trusted practitioner for brand recommendations. In the US, supplements are unregulated which means there isn’t much in the way of quality control. The bottle you pick up at a drugstore may not even contain what it claims. That’s why it’s so important to purchase neutraceutical grade supplements sold through a licensed provider.
Myoinositol at 4 gm per day
Myo-Inositol resensitizes insulin receptors. The research on myo-inositol shows positive effects including improvements in blood pressure, LH, LH/ FSH ratio and total and free testosterone.
NAC at 1200-1800 mg per day
N-acetyl-cysteine was compared to metformin in PCOS treatment and shown to be more effective. The women in the study took 600mg 3 times a day for 24 weeks.
Magnesium Glycinate at 300 mg per day
Magnesium is another fantastic supplement and one that almost every woman should take. From a PCOS perspective, it is another good helper for blood sugar balance.
CoQ10 at 600 mg a day
There are lots of positive studies showing that CoQ10 is good for those mighty mitochondria in your cells. One study conducted in 2014 showed positive results for women who are resistant to clomiphene (aka clomid), common in women with PCOS.
Women with PCOS can have higher than normal levels of cortisol – that hormone you remember from all of the commercials telling you it causes belly fat. When cortisol levels are higher, you are more likely to crave sugar and fatty non-nutritional foods. There are many great ways to decrease cortisol. Acupuncture and therapeutic massage have been shown to optimize and balance cortisol levels. Finding stress management tools that resonate with you are key. Check out a yoga class or try listening to a meditation. As mentioned above, exercise can be helpful for insulin but it can also help folks moderate their stress. Take your walk out into the woods for an added stress busting element.
ACUPUNCTURE and CHINESE HERBAL MEDICINE
From a Traditional Chinese Medicine (TCM) perspective, there are 3 organs that come into play when we are talking about PCOS: the Spleen, the Liver, and the Kidneys. Much like identifying your PCOS type, your acupuncturist will identify which organs are most in need of support.
Spleen Qi Deficiency is one of the most common underlying diagnosis for PCOS. There are some who think the Spleen is a mistranslation from the Chinese and that the Spleen I learned about in acupuncture school is actually your pancreas! Your pancreas has a huge role to play in the metabolism of glucose (sugar). In Chinese Medicine, the Spleen is thought to help us absorb nutrients from the food that we eat and helps us maintain a healthy weight. Since insulin resistance is a primary piece of the PCOS puzzle and excess weight is something many women with PCOS struggle with, no wonder most women with PCOS have Spleen Qi Deficiency! Some additional signs of Spleen Qi Deficiency might include loose stools, worry, and fatigue.
The liver has the job of ensuring the smooth flow of Qi in our body. When qi is not flowing smoothly, people get what we call Liver Qi Stagnation. If the Liver Qi Stagnation goes unchecked, it can lead to heat. This heat builds up in the system and can create some of the cystic acne that women with PCOS experience. Additional signs of Liver Qi Stagnation include PMS irritability and breast tenderness.
The Kidneys are vital to reproduction in general. In TCM, when you are born, all of the life force energy that you have for the rest of your life is stored right between the kidneys. The absence of menstruation or ovulation is an indication that the kidneys need nourishment. Many genetic conditions come from a deficiency of Kidney qi or even jing (essence). Owing to the fact that the research is showing a very clear genetic component to PCOS, it isn’t surprising that this is an organ that often needs attention.
Your acupuncturist will choose acupuncture points and possibly herbal protocols based on your constitutional diagnosis to support balance in all of your major body systems. This balance helps to rectify organ imbalances in order to optimize ovulation, treat PCOS, and enhance fertility.
If I’m not trying to conceive, should I be worried if I have PCOS?
Even if conception isn’t on the radar for you, there are some unfortunate health issues that can result from unmanaged PCOS. There is an increased risk of cardiovascular disease, diabetes, and even endometrial cancer. Restoring ovulation and regular menstruation is key to PCOS management. Making the changes to better your health will help you prepare for future conception, to feel better in your body and protect long term health.
If you are in the Lexington area and would like help managing PCOS and/ or irregular cycles, we’d love to help. We treat women just like you every day.