PCOS (Polycystic Ovarian Syndrome) is one of the most important conditions we absolutely need to raise awareness about worldwide. It is the most common endocrine condition in young women globally and when left undiagnosed and untreated, it significantly raises the risk of health conditions like obesity, diabetes and heart disease in multiple generations. The global incidence of PCOS ranges from 20-30% and certain ethnic groups are at higher risk as we'll discuss later in this post.
“In fact, this review article cites a study in the UK that found 52% of South Asian female immigrants had PCOS.”
The ongoing crisis of diabetes and heart disease in countries like India may be partially attributed to young women with PCOS, which plants the seed of heart disease and other chronic health conditions in future generations as we'll learn later in this post.
In fact PCOS has become so common in ethnic groups like South Asians that I presume most South Asian women have PCOS or “pre-PCOS” until proven otherwise, especially if their is any family history of insulin resistance (diabetes, cholesterol disorders, heart disease, etc.), which there usually is. This may sound extreme, but given that up to 70 percent of PCOS cases are missed, I think we need to err on the side of being oversensitive in our approaches to detection.
The tragedy of PCOS is that it is often unrecognized and undiagnosed until later in life and in many cases it is never diagnosed. In the mean time, young girls and women struggle with the physical and emotional consequences of symptoms like excess body fat, hirsutism (hair growth on the face, limbs and elsewhere), acne, and infertility.
I'm going to dive deep in this post so you understand PCOS and its common manifestations. PCOS is a diagnosis that families need to think about since busy doctors often miss it. The signs and symptoms can be subtle and if not caught early can manifest with more significant conditions later on. We'll also talk about cultural variations in PCOS and then end with 7 key lifestyle changes to help prevent, manage and possibly reverse PCOS.
The PCOS Misnomer
One of the reasons PCOS is underrecognized is because the name does not even represent the most common symptoms women present with. See the key features and their incidence listed below from a cohort of 1380 women with PCOS, summarized in this review article.
- Difficulty losing weight 56.2%
- Irregular menstrual cycles 52.3%
- Infertility 44.4%
- Hormone imbalance 41.7%
- Insulin resistance 35.6%
- Excess hair growth 35.2%
- Increased tendency to gain weight 31.3%
- Anxiety and/or depression 24.4%
- Increased metabolic risk 13.9%
- Scalp hair loss 11.4%
- Pregnancy complications 11%
- Ovarian cysts 10.7%
“Notice how the ovarian cysts, which is what the condition is named after, is the LEAST COMMON feature of the condition!”
Many specialists around the world are calling for the renaming of this condition to help raise public awareness. If I personally were to rename the condition I would call it something like IROS for “Insulin Resistant Ovarian Syndrome” since insulin resistance is much more of a hallmark feature than cysts in the ovaries.
What Is PCOS?
So if the condition is named after ovarian cysts, but ovarian cysts are an infrequent occurrence, then what exactly is PCOS? Most cases of PCOS have insulin resistance as a root cause, which you can read about here. When the body's cells become resistant to insulin, the pancreas responds by producing more insulin.
Excess insulin stimulates the ovaries to produce more male hormones called androgens and causes the liver to produce less SHBG (sex hormone binding globulin), which increases the amount of active or “free” testosterone.
These androgens along with excess insulin in turn trigger more visceral fat (aka “belly fat”) formation which worsens insulin resistance further, causing a vicious cycle displayed below:
To briefly summarize this process:
Insulin resistance –> Excess Insulin –> Excess Androgen production –> Androgenic Symptoms (described below) and more visceral fat –> worsening insulin resistance —> Worsening PCOS –> etc.
Now lets discuss the primary types of symptoms:
1. Androgenic Symptoms: As we discussed already, excess androgens are a byproduct of PCOS. Androgens like testosterone are the hormones that give humans male-type characteristics. Normal females do have androgens, but in abundance they can cause some of the following characteristics
–Hirsutism: Hair growth that occurs in a male pattern on various areas of the face (upper lip, chin, etc.) and body. The image below shows an easily noticeable case of hirsutism, but in some women it can be subtle.
–Acne: Excess testosterone causes the sebaceous glands in our skin to produce more oil or sebum, which can trigger acne. This study showed that over half of women with more severe, resistant acne had PCOS. The woman pictured above has both hirsutism and acne.
–Alopecia: This is male pattern balding/hair thinning over the scalp that can occur in women with PCOS. Excess testosterone in men and women causes hair thinning, which is why medications for hair loss target excess testosterone production. So for women with PCOS, they can have the unfortunate combination of hirsutism (excess hair on non-scalp areas like the face) and balding over the scalp.
2. Obesity: The elevated insulin levels in PCOS lead to increased fat storage and as discussed, the elevated androgen levels can lead to a greater distribution of visceral/belly fat.
In addition to excess body fat, women with PCOS often have a very difficult time losing weight despite repeatedly going on low calorie diets and increasing exercise. One of the fundamental reasons for this form of resistant weight loss is because it is due to a more complex hormonal imbalance, rather than a caloric imbalance.
Hormones such as insulin, sex hormones like androgens, and the stress hormone cortisol are just a few of the hormones that when simultaneously disrupted, can make weight loss very challenging.
“Excessive low calorie dieting and overexercising can often make the hormonal issues worse, leading to no weight loss or even weight gain.”
3. Insulin Resistance: As discussed, insulin resistance is often the root cause for PCOS. Read more about insulin resistance here and in my book. I've listed some of the typical symptoms below:
- Cholesterol abnormalities, particularly high triglycerides and low HDL (good cholesterol)
- Abdominal obesity (increased belly fat)
- Elevated blood glucose
- High blood pressure
Metabolic syndrome, which I wrote about here, is a condition that specifically outlines key features of insulin resistance. Women with PCOS have a higher risk of metabolic syndrome which in turn significantly raises diabetes and heart disease risk.
A dark, hyperpigmented skin condition called Acanthosis Nigricans can also be present in insulin resistance and/or PCOS. Acanthosis commonly occurs in areas like the neck, armpit, groin and skin folds. See image below.
4. Menstrual Irregularities: With PCOS periods may be irregular or may stop altogether. The average menstrual cycle is between 21 to 35 days, so an irregular period may last more than 35 days or a woman may experience eight or less menstrual cycles per year.
5. Infertility: For many women, infertility is the first time they are diagnosed with PCOS. Earlier in life they may not have had the other manifestations, or the symptoms may have been too subtle to notice.
Below is an infographic I made summarizing the key symptoms. I also mention some of the cultural variations which we'll discuss later in the post.
PCOS is primarily a clinical diagnosis based on the symptoms we just discussed. Your doctor may check hormone levels and they may return normal, but if you have signs of insulin resistance especially combined with acne, hirsutism, etc., it is likely you have PCOS. I again want to emphasize that a normal ultrasound does not mean you are clear of PCOS since ovarian cysts are not a common feature.
Many doctors diagnose PCOS based on the Rotterdam criteria explained here. Unfortunately these criteria do not include the features of insulin resistance we discussed earlier.
Some typical lab tests done for PCOS may include a testosterone level, DHEA, LH and FSH hormone levels, TSH (thyroid hormone), prolactin, and labs for insulin resistance like fasting lipids, glucose, hemoglobin A1C (3 month marker of abnormal glucose), and possibly a glucose tolerance test (aka GTT). Ultrasound to look for cysts is typically done as well.
PCOS not only increases the risk of multiple health conditions in affected women, but risk is also increased in the children of PCOS mothers. Below are partial lists of some of the conditions women with PCOS and their children are exposed to:
Risks to women with PCOS
- Infertility: PCOS is the number one cause of infertility in women.
- Insulin resistance in 50-70% of women which can manifest as any combination of:
- Type 2 Diabetes
- Cholesterol disorders
- Fatty Liver….and more.
- Heart Disease risk is anywhere from 2-7 times greater in women with PCOS since it's associated with the major heart attack risk factors mentioned above (diabetes, cholesterol, obesity, etc.).
- Mental Health: 60% of PCOS women have at least one mental health problem like depression, anxiety or an eating disorder, and they also have a higher risk for suicide. Read this article for details.
- Endometrial cancer risk is doubled
Risks to children of PCOS mothers
- Increased risk of insulin resistance and Type 2 diabetes
- Increased risk of heart disease later in life
- Autism: read this article in Scientific American which suggests increased prenatal androgen (male hormone) exposure to the fetus from PCOS mothers can increase the risk of autism
- Daughters of PCOS mothers have up to 8 times higher risk of developing PCOS
Cultural Variations in PCOS
By this time you may recognize that PCOS is a complex condition with a variety of different symptoms which varies in presentation. As discussed, ovarian cysts tend to be less common. One woman may have full blown PCOS with hirsutism, acne, obesity, menstrual irregularities and abnormal blood glucose. Another woman may be slender with no other symptoms other than slight acne. What accounts for such variation?
Culture plays a significant role. This article is a great review of how PCOS presents differently in different ethnic groups and explains it nicely with the following quote:
“Although from the same species, the world's populations vary in physical, behavioral and social distinctiveness based particularly on ancestry and geographic segregation. Natural selection of genes and adaptation to environmental conditions has caused these variations…”
I've listed a summary of some of the key cultural variations below. Remember “hirsute” or “hirsutism” means more hair on the face and other areas apart from the scalp.
South Asians (Indians, Pakistanis, Bangladeshis, etc.)
- Migrant Asian Indians (living in South Africa) have greater insulin resistance versus white caucasians
- UK-based south Asians of Pakistani origin have more severe manifestations at a younger age with greater insulin resistance when compared with white Europeans
- Indigenous South Asians at a younger age and with a lower BMI have greater insulin resistance and metabolic abnormalities than obese white Caucasians with central obesity (abdominal fat) rather than BMI correlating with metabolic changes
- South Asians have a high risk of insulin resistance and metabolic syndrome, regardless of whether they have hirsutism or not
East Asians (Chinese, Japanese, Taiwanese, etc.)
- Japanese versus Italians and Hispanic Americans – the Japanese have less hirsutism with lower BMI, but labs show similar level of excess androgens and insulin resistance compared to white Europeans.
- East Asians (Chinese, Japanese, etc.) have less hirsutism than other ethnic groups and if they have hirsutism, it indicates a much higher risk of insulin resistance and type 2 diabetes
- African–Americans with PCOS have a greater propensity for obesity and hypertension than Type 2 Diabetes
- African–American women bear a disproportionate burden of heart disease risk factors compared to other ethnic groups
- African-American women tend to have less androgenic symptoms than Asians, Hispanics and Caucasians
- Hispanics, like South Asians, have a higher incidence of PCOS than most other ethnic groups.
- This study shows that hispanic women with PCOS show higher rates of androgenic symptoms and heart disease risk (also similar to South Asians).
7 Steps to Prevention and Potential Cure of PCOS
The traditional approach to treating PCOS is focused on treating symptoms with medications rather than focusing on the root cause. For example, taking birth control pills for irregular periods or medications for acne and hirsutism.
1. Beat Insulin Resistance: If you want to cut PCOS out from the root, you need to understand and eradicate insulin resistance. The good news is most cases of insulin resistance are completely reversible through lifestyle changes. I highlight a case study in my book of a woman who reversed PCOS and regained fertility through lifestyle changes.
Please use my blog and my book as initial resources, and for an innovative way to understand and reverse PCOS using cutting edge animations and continuously updated content, consider trying my self-paced online RID program. I have several PCOS sufferers who have signed up for the program. Essentially, you need to eat a nutrient dense, low glycemic, anti-inflammatory diet as a first step towards reversing insulin resistance and PCOS.
2. Correct Key Micronutrient Deficiencies: Remember, you can be on a low fat, low carb, low calorie, vegan and/or vegetarian diet and still suffer from significant micronutrient deficiencies that put you at risk for PCOS. I've listed some of the major ones below:
- B-vitamin deficiencies: B12 deficiency is linked to insulin resistance and in pregnant mothers can increase the risk of type 2 diabetes in the child. In addition, the long-term use of common medications used to treat PCOS like metformin and oral contraceptives can contribute to B12 deficiency. Talk to your doctor about checking B12 levels and be sure to include B12-rich foods and consider supplementation under your doctor's supervision.
- Magnesium deficiency: A magnesium-rich diet can help reduce insulin resistance and can also combat some of the symptoms of PCOS like PMS, migraines, mood disorders and fatigue. Magnesium-rich foods include spinach, swiss chard, pumpkin seeds, almonds, dark chocolate (70% plus in moderation), avocados, etc.
- Zinc deficiency: associated with low androgens and acne. Eat zinc-rich foods like nuts, seeds (pumpkin, sesame), certain meats (grass-fed lamb and beef in moderation), beans (garbanzos in moderation), unsweetened kefir/yogurt, spinach, etc.
- Vitamin D deficiency: Deficient vitamin D is associated with insulin resistance and is commonly low in PCOS. Read my post on vitamin D here.
- Iron deficiency: Iron deficiency is often a consequence of PCOS, especially if women have heavy or prolonged periods. Iron deficiency in turn can make symptoms of PCOS worse like fatigue and mood disorders. Talk to your doctor to see if iron levels need to be checked and eat an iron-rich diet.
My typical vegetarian patients in particular are at very high risk for all of the deficiencies listed above. I'm not encouraging meat consumption if you are vegetarian, but you do need to make an active effort to include many of the foods listed above and to talk to your doctor about screening and potentially supplementing in case there are diagnosed deficiencies.
My non-vegetarian patients aren't off the hook either. Many of my busy families are eating nutrient deficient meals on the run or are deliberately or inadvertently missing meals in a failed effort to perform intermittent fasting, which requires a more balanced approach. Read about fasting here.
In addition to eating a diet deficient in nutrients, an excessive intake of wheat and grain-based products can bind many of the key minerals mentioned above (zinc, magnesium, vitamin D, etc.) due to to a substance called phytic acid which you can read about here. Eating the wrong foods and excluding the right foods together increase the risk of PCOS and most chronic health conditions.
3. Eliminate Toxin Exposures: We are exposed to numerous toxins that can wreak havoc on hormonal health and increase the risk of conditions like PCOS. Toxins that interfere with hormone function are known as “endocrine disrupting chemicals” or EDCs and the most commonly studied ones are found in plastics like Bisphenol A (aka BPA). Some tips for reducing exposure:
- Replace plastic food containers and water bottles with glass and stainless steel
- Examine all skin care products (cosmetics), household products, etc. and opt for “green” options.
- Eat/drink the cleanest, most natural diet possible, including the water you drink
- Use the EWG website here as a comprehensive resource for clean skin care products, foods, etc.
Fetal exposure to such toxins can actually increase the risk of PCOS and other health conditions as outlined in this study. The developing fetus is especially sensitive to the effects of toxin exposures which influence and shape their genetic blueprint. It is imperative that mothers do everything possible to minimize toxin exposures during pregnancy.
Now maybe you live in the heart of industrial China or India, where it's challenging to limit environmental pollution and other exposures. The good news is even if you can't reduce the intake of toxins, you can enhance your body's ability to remove them.
For example, a chemical in cruciferous vegetables (broccoli, cauliflower, brussel sprouts, etc.) called sulforaphane activates detoxifying pathways in the body that help remove toxins. This study was done in industrial China where participants had significant exposure to the carcinogen substance, benzene.
“Study participants who consumed a broccoli sprout beverage from day one had a 61% increase in excretion (removal) of benzene from their body.”
Eating a multicolored plant-rich, nutrient-dense diet, while drinking lots of water and even detoxifying beverages like green tea can help provide your body with fortification from a wide variety of environmental insults.
4. Improve Emotional Health and Sleep: Sleep deprivation and chronic stress are major root causes for insulin resistance and micronutrient deficiencies. Here in Silicon Valley, I see the tremendous pressure parents place on their children to achieve the best. I've blogged and spoken on this topic before. If such pressure is coming at the cost of a nutritious diet, regular physical activity and adequate rest and sleep, then we are putting our children at risk. If you are the parent of a daughter, just know that I consider Type A parenting to be a major trigger to PCOS because it leads to virtually all of the risk factors we've discussed so far.
5. Consider Cutting Back or Eliminating Dairy: There are some studies connecting PCOS to dairy intake, but the connection is not definitive by any means. Interestingly it appears low fat and skim milk cause a higher risk than full fat milk and in this post we discussed in detail the benefits of full fat dairy over skim. Dairy can increase androgen production and worsen certain symptoms like acne. I've recommended women cut dairy for 3-4 weeks and then re-introduce to see if symptoms flare. Often acne clears up completely during this period. Some women benefit from complete dairy elimination while others do fine with cutting their dairy servings to no more than 2 per day and emphasizing fermented dairy (kefir, yogurt) and high quality grass-fed full fat dairy.
6. Eat More Omega-3s: While eating excess dairy may increase androgens, consuming more Omega-3s can reduce them as seen in this study. Eat foods rich in these healthy fats like cold water fish (Salmon, Mackerel, Albacore Tuna, Sardines, etc.), nuts (especially walnuts), seeds (chia and flax), and egg yolks.
7. Increase Physical Activity: You need to stay physically active to keep blood glucose and insulin levels low, which helps mitigate insulin resistance. Although exercise is important, keep in mind that diet is key. I have many female patients who have been physically active their whole life but developed insulin resistant conditions like type 2 diabetes and PCOS due to a suboptimal diet. Read my 2-part series on exercise which starts here.
Protect Future Generations
I had a woman come see me in the clinic with her 13-year-old daughter. Although I don't treat children, it was obvious from what the mother told me that she had PCOS when she was young and her daughter was headed in the same direction. When I told her about some of the changes she and her daughter should make, I got the following response which I'm generously paraphrasing:
“I know she is following in my footsteps with PCOS, but I don't know how to stop it. She gets hours of homework and between her debate class, piano practice, math enrichment and young entrepreneur's group, there's absolutely no time for exercise and I just can't find time to cook health meals.”
I told her to close her eyes for a moment and look into a future where her daughter may face the prospect of being infertile, of becoming diabetic, or developing heart disease or of her own grandchildren developing similar conditions in the future. These are the risks young girls with PCOS and their future offspring potentially face later in life if they don't incorporate a healthy lifestyle.
Getting straight As should all of a sudden seem so insignificant if the trade-off is developing any of these health issues. Unfortunately many families I see in the clinic have created a helpless narrative where they do not have the time to instill proper nutrition and lifestyle habits due to the academic pressures around them.
The good news is when families make the right changes, children benefit from more energy, more focus and better academic performance, in addition to improved overall physical and emotional health. Rewrite the narrative and start making changes now. If you're like me, you should consider the health of your children a top priority above all else. If their schedule is getting in the way of their health, you need to cut back their schedule. Don't compromise!
We cannot reverse the risks passed on from prior generations, but we can do everything possible to reduce and potentially eliminate current and future risk through behavior changes. We're not just talking about the health of your daughters, but of your grandchildren also. Again, follow the chain below:
“PCOS in teenage girl–>infertility or gestational diabetes in young woman–>increased future risk of diabetes and heart disease in woman and her children.”
These are devastating and potentially deadly health conditions that can be prevented in most cases through simple changes like improving the diet (cut back sugar, packaged/processed foods and eat more natural foods), being a little more active (sit less, move more), and lower toxin burden (replace BPA-free containing plastic food containers and bottles with glass ones, etc.). Small changes, but HUGE intergenerational health impact.
Join me and spread the word about PCOS to your family, to your community, to girls and women worldwide. Share this blog post as a start and let's try to raise awareness so future generations don't continue to suffer.