So, you have a PCOS diagnosis
Once you have this diagnosis, then your provider may recommend one or all of these treatments:
- Weight loss if you are above optimal body weight (magic wand not included).
- Birth control pills to “regulate” your period and reduce the number of androgens circulating around your body.
- Synthetic progestin therapy to reduce the heavy bleeding when you DO get a period.
- Metformin, an insulin-sensitizing drug to reduce insulin excess and prompt you to ovulate.
- Spironolactone (an androgen receptor blocker) to reduce the symptoms of hair loss, excessive facial and body hair and acne.
But if you want to become pregnant, the recommendations shift:
- Lose weight if you are above your optimal body weight.
- Take Clomid (a drug that stimulates ovulation) and Metformin (to improve chances of ovulating).
- “Run, don’t walk” to the nearest fertility specialist for ovulation-inducing drugs, insemination, and/or in vitro fertilization (IVF).
Sadly, this menu of treatment hasn’t changed in the last 20 plus years, despite emerging research that describes the various underlying causes of PCOS. However, when we know the causes, we can reduce and possibly reverse the impact of this condition.
Here we discuss many common causes of PCOS, and the tests to identify these conditions.
What are the most common causes of PCOS?
If you have a PCOS diagnosis, you likely have one or more underlying causes. Therefore, it’s important for you to address each one to improve your health and reduce or reverse your symptoms and associated risks.
These are many of the most common PCOS triggers and causes:
- Insulin resistance (70% of cases)
- Chronic inflammation and toxic environmental exposures (overlaps with most PCOS types)
- Androgen excess (occurs with most forms of PCOS)
- Adrenal stress hormone imbalance (10-20% of cases)
- Post-pill amenorrhea (not getting your period after stopping birth control pills)
How to test for insulin resistant-type PCOS
Insulin resistance refers to your body’s reduced ability to respond to insulin. In a nutshell, chronic high blood sugar raises insulin, which in turn remains elevated. Consequently, high insulin levels cause your ovaries to produce higher than normal levels of testosterone. However, not all women with high insulin respond in this way because your genes play a role in whether or not you develop insulin resistance and PCOS.
Causes of insulin resistance
- Standard American Diet (SAD) — high processed foods, high sugar, high fructose, low vegetables, alcohol, and trans-fat intake
- Hormonal birth control
- Sleep deprivation
- Unhealthy gut bacteria
- Magnesium deficiency
- Environmental toxins
Tests for insulin resistance
- Fasting insulin (ideally less than 10) — if high, precedes the development of pre-diabetes and diabetes
- Fasting glucose (ideally less than 90) — high in pre-diabetes and diabetes
- Hemoglobin A1C (ideally less than 5.4) — high in pre-diabetes and diabetes
- Two-hour oral glucose and insulin tolerance test (a challenge test to see how you handle a high sugar load)
- SHBG (sex hormone binding globulin) — low with both elevated androgen levels AND insulin resistance
- Serum magnesium levels — may be low with insulin resistance
So if you have evidence of insulin resistance, assess your risk of developing heart disease with these tests:
- Lipid panel — HDL, LDL, triglycerides and total cholesterol. In addition, LDL-P (particle number) gives more information about your risk factors.
- Vitamin D — low levels increase your risk for insulin resistance, inflammation, hormone imbalance, immune system dysfunction and diabetes.
How to test for inflammation-type PCOS
Chronic inflammation activates your immune system. Therefore if you notice symptoms such as unexplained fatigue, headaches, joint and muscle aches, allergies, sinus congestion, skin rashes or chronic skin conditions, you may fall into this category. It turns out inflammation-induced PCOS occurs for a variety of reasons:
- Gastrointestinal infections
- Food sensitivity or intolerance
- Environmental toxin exposures and heavy metal exposures
- Chronic stress
- Chronic viral or bacterial infections
- Mold exposure
- Autoimmune diseases
Furthermore, inflammation feeds insulin resistance through various mechanisms and alters normal hormone receptor signaling. It’s important to know your baseline levels of inflammation, to monitor your progress. If you find that you DO have inflammation, you can search for the causes and treat them.
Tests for inflammation:
- High sensitivity C-reactive protein — levels above 3 indicate high levels of inflammation, below 1 is ideal.
- Homocysteine — a metabolite of folate which is often elevated with inflammation. We aim for levels below 8.
- ESR (erythrocyte sedimentation rate) — a non-specific but often useful measure of inflammation. Anything above the lab range is an indicator of inflammation.
- CBC — very low or very high white blood cell counts with a shift of lymphocytes, eosinophils or neutrophils (different types of white blood cells that fight infections) may indicate a simmering, persistent infection.
Furthermore, if you have a family history of autoimmune disease, or you suspect you may have an autoimmune disease, these tests are a start:
- ANA titer (a general screening test for autoimmune risk) — greater than 1:40 is suggestive of autoimmunity.
- Anti-TPO, Anti-TG and TSI Antibodies — screen for autoimmune thyroid disorders often correlate with PCOS.
How to test for excess androgen-type PCOS
First of all, androgen hormone tests should be part of a standard PCOS evaluation, because these help to figure out what therapies you need to reduce and reverse your symptoms.
Tests for excess androgens:
- Adrenal androgens (implies the source of androgens is related to adrenal issues)
- DHEA-S — may be elevated in PCOS or if VERY high (>700) may indicate other adrenal conditions.
- Androstenedione — may be elevated in PCOS.
- 17-OH progesterone — if this is elevated, suspect congenital adrenal hyperplasia which is NOT PCOS.
- Cortisol — to rule out Cushing syndrome.
- Ovarian androgens:
- Total and free testosterone levels — may be elevated in PCOS.
- Androstenedione — may be elevated in PCOS.
- Other markers of androgen excess:
- SHBG (sex hormone binding globulin) — may be reduced in PCOS when androgens are high.
How to test for post-pill PCOS
This is PCOS following the use of hormonal contraception. If you had normal periods prior to starting hormonal contraception and then developed signs of PCOS once you stopped it, you most likely fall into this camp.
Progestin in most birth control pills and hormonal IUDs can have pro-androgen effects. (A progestin refers to a synthetic, non-bioidentical version of progesterone, the hormone that your own body makes). Consequently, this can increase your risk of insulin resistance, especially if you are genetically predisposed to PCOS. When you stop pro-androgen progestin (such as the newer 3rd and 4th generation birth control pills), you can experience a rebound release of excess androgens, as your SHBG drops. By the way, SHBG is a protein made by the liver that acts as a sponge to bind excess circulating hormones.
Tests for post-pill PCOS
- LH and FSH levels (pituitary hormones known as luteinizing hormone and follicle stimulating hormone) may be the only sign of post-pill PCOS. Typically the ratio of LH to FSH is greater than 2:1 or 3:1.
- Elevations in androgen levels are common.
- Insulin resistance is NOT typically found in post-pill PCOS.
How to test for adrenal-type PCOS (stress hormone imbalance)
In 10-20% of cases, PCOS may be the result of an abnormal adrenal response to stress in the HPA (hypothalamic-pituitary-adrenal) axis.
When you endure chronic stressors, whether emotional, psychological or physiological, your adrenal glands produce cortisol, adrenaline and the adrenal androgen (“male”) hormones DHEA and androstenedione. Consequently, in most cases of adrenal PCOS these androgens convert to testosterone, although this has nothing to do with insulin resistance or abnormal ovarian hormones.
First and foremost, you must address your stress in order to control your symptoms or reverse your PCOS. Hence significant lifestyle work is absolutely necessary to fix your PCOS. The PCOS SOLUTION program guides you through the steps to do this, easily.
Tests for adrenal-type PCOS
- If your DHEA-S levels are high but serum testosterone is not, this may be adrenal PCOS.
- DUTCH hormone testing by Precision Analytics is a comprehensive urine test to check for HPA axis abnormalities. A Functional Medicine practitioner can order this test, and specifically, treat your stress hormone imbalances.
So, now that you may understand more about the underlying causes of your PCOS, it is time to fix them!
Enroll in The PCOS SOLUTION program, a 6-week experiential program that addresses all of these underlying causes of PCOS, and more. Learn how to take control of your hormone health without the use of harsh drugs that only mask your symptoms. Fix your PCOS today!