What is Polycystic Ovary Syndrome (PCOS)
1 in 10 women in the UK have PCOS and according to Verity, a UK PCOS charity, 70% of people do not know they have it (1) . It is more common in caucasian women, middle eastern women, and black women (2). Women with PCOS have an increased risk of developing type 2 diabetes and heart disease in the long term (3).
The term ‘polycystic ovary syndrome’ is actually quite confusing as it implies that the problem lies mainly with the ovaries and the multiple ‘cysts’ on the ovaries. However, the cause of PCOS is due to insulin and androgens hormone imbalances and affects not just the ovaries.
It is thought that increased levels of insulin in the body cause the ovaries to work differently, which then produce excessive levels of male-type hormones (androgens). This in turn causes many of the symptoms of PCOS.
Research suggests that there is a genetic element to the PCOS as it can run in families, although specific genes associated with the condition have not yet been identified. The gene(s) can be affected by the environment, lifestyle factors, or both (3).
Symptoms of PCOS
No woman with PCOS is the same in terms of symptom presentation and their severity. Common symptoms include:
- Irregular periods or no periods at all
- Fertility issues and difficulty getting pregnant (because of irregular ovulation or no ovulation)
- Excessive hair growth (hirsutism)
- Weight gain
- Hair loss
- Oily skin and/or acne (3)
How is it diagnosed
According to the NHS (5), the diagnosis of PCOS can usually be made if other rare causes of the same symptoms have been ruled out and you meet at least 2 of the following 3 criteria (you will not necessarily need to have an ultrasound scan before the condition can be confirmed if 2 symptoms are present):
- You have irregular periods or infrequent period. This indicates that your ovaries do not regularly release eggs (ovulate)
- Blood tests showing you have high levels of “male hormones”, such as testosterone (or sometimes just the signs of excess male hormones, even if the blood test is normal)
- Scans showing you have polycystic ovaries with a number of fluid-filled sacs (follicles) surrounding the eggs in the ovaries. Despite the name ‘polycystic ovaries’, they are not cysts.
What happens when you are diagnosed with PCOS
Once diagnosed, you may be treated by your GP or referred to a specialist. Specialist referrals would be directed towards either a gynaecologist (specialist of the female reproductive system) or an endocrinologist (a specialist in treating hormone problems) (5). Registered dietitians, like myself, who specialise in PCOS can help with dietary and lifestyle recommendations that can improve your symptoms.
According to International guidelines for PCOS, factors such as blood glucose, weight, blood pressure, smoking, alcohol, diet, exercise, sleep and mental, emotional and sexual health need to be optimized (3). If the hormone levels can be controlled, the ovaries often function normally, and symptoms improve. Although medication is important, lifestyle changes should be prioritised in PCOS (4).
It is not always about weight management in PCOS, although if overweight a relatively low reduction in weight (over 5%) is adequate to improve insulin resistance, ovulatory dysfunction and fertility.
Practical recommendations
Based on the International PCOS guidelines (5) and a large systematic review of the dietary composition in the treatment of polycystic ovary syndrome (7), try the following:
Make sure your meals are regular and balanced:
Do not skip your meals to ensure stable blood glucose control and to avoid overeating.
Focus on positive change!
Think of what you can add to your diet and avoid strict restrictions. Individuals who restrict their diet are more likely to choose unhealthy foods in response to negative emotions (6).
Choose low Glycaemic index (GI) carbohydrates – wholegrains over white ones:
A low-glycaemic index diet was associated with improved menstrual regularity and improved quality of life according to a large systematic review in 2012 (7). Both a low-carbohydrate or low-glycaemic index diet were associated with reductions in insulin resistance, total, and HDL cholesterol.
Include good healthy fats and lean protein with each meal to have a low-glycaemic load meal:
This is less likely to cause spikes of blood glucose and reduce insulin resistance. Extra virgin olive oil, nuts, seeds, avocado and lean beef, pork, chicken, turkey, eggs, tofu are all good examples. A diet rich in monounsaturated fats has been associated with greater weight loss and a high-protein diet was associated with improved depression and self-esteem (7).
Increase fibre!
Fibre is very important as it influences our gut microbial composition. Focus on getting 30 g of fibre daily and include a rainbow variety of fruits and vegetables. This will naturally increase antioxidants and work to reduce PCOS inflammation. It will also increase essential prebiotics to feed gut microbes.
Consider fish or Omega 3:
Consume fish at least 2 – 3 times per week (300 – 350g) where possible. Alternatively, invest in a good quality Omega 3 supplement for long-chain, omega-3 fatty acids (particularly DH) which will reduce the inflammation in the body.
Watch your stress levels:
Learning to manage your stress levels is a very important factor in PCOS. Do something you enjoy, such as practicing mindfulness and meditation or try yoga and pilates. High stress situations can also cause a negative mood that can lead to comfort eating with unhealthy foods and overeating or binging (6).
Be more active!
This is important for weight management or weight loss, improving insulin resistance and fertility in PCOS. The level and severity of activity differs depending on age (5), but aiming for moderate physical activity, 3-5 times a week is a good start.
Invest in your sleep quantity and quality:
Poor sleep habits can impact on the stress hormone cortisol levels and also play havoc with your appetite regulation.
Gut Microbiota(GM) and PCOS
Reduced microbial diversity has been shown to be associated with various diseases. Gut dysbiosis is a term that can be defined as the imbalance of gut microbiota (GM) associated with an unhealthy outcome and involves the loss of beneficial microbes and an increase in pathogenic microbes (8). Dysbiosis can be caused by several factors such as poor diet, lack of exercise and sleep, infections and use of antibiotics to name a few.
The stool microbiome, gut permeability, and inflammatory status of women with PCOS has been researched. Overall, it was found that GM of women with PCOS showed a lower diversity compared to controls and that an altered GM significantly correlated with PCOS phenotype, so was dependent on the certain criteria that women with PCOS had (9). Insulin resistance, hirsutism, sex hormone concentrations (especially total testosterone), and obesity were amongst the main aspects that affected diversity and composition of GM in studied women with PCOS (9,10,11).
One study (10) suggested that androgens may be an important factor in modulating the gut microbiome and that changes in the gut microbiome may influence the development and pathology of PCOS. Diet wise, it was also found that the intake of dietary fibre and vitamin D were significantly decreased in those with PCOS (9).
In summary
PCOS is a common and complex endocrine condition. Medical treatment is often advised at diagnosis, however dietary and lifestyle interventions should be prioritised as they can drastically improve PCOS symptoms. Gut dysbiosis is a common feature of PCOS and may pose a promising future treatment option. Increased prebiotic fibre and greater diversity of plant foods in the diet, addition of probiotics and improved stress, sleep and physical activity may positively modulate microbial balance in the gut.
Given the findings that some women with PCOS tend to have lower fibre intake, it is essential to promote gut optimisation with increased plant food diversity as well as ensuring optimum status of vitamin D with correct supplementation.
Need extra support?
If you have just been diagnosed with PCOS or have had it for a long time and are struggling, book an appointment with the Gut Health Clinic for a more individual assessment and tailored advice!
References
- Verity PCOS charity, accessed 07/02/2023 http://www.verity-pcos.org.uk/
- Ding T, Hardiman P , Petersen I , Wang F-F, Qu F, Baio G. The prevalence of polycystic ovary syndrome in reproductive-aged women of different ethnicity: a systematic review and meta-analysis.Oncotarget 2017 Jul 12;8(56):96351-96358.
- Norman RJ, Dewailly D, Legro RS, Hickey TE. Polycystic ovary syndrome. Lancet. 2007;370:685–697.
- Helena J Teede et al. Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. International PCOS Network Author Notes. Human Reproduction, Volume 33, Issue 9, September 2018, Pages 1602–1618.
- NHS PCOS accessed on 07/02/23 https://www.nhs.uk/conditions/polycystic-ovary-syndrome-pcos/
- Mantau A, Hattula S, Bornemann T. Individual determinants of emotional eating: A simultaneous investigation. Appetite. 2018;130:93-103
- Moran LJ, Ko H, Misso M, Marsh K, Noakes M, Talbot M, et al. Dietary composition in the treatment of polycystic ovary syndrome: a systematic review to inform evidence-based guidelines. J Acad Nutr Diet. 2013;113(4):520-45.
- Donaldson GP, Lee SM, Mazmanian SK. Gut biogeography of the bacterial microbiota. Nat Rev Microbiol. 2016;14(1):20–32.
- Lindheim L, Bashir M, Munzker J, Trummer C, Zachhuber V, Leber B, et al. Alterations in gut microbiome composition and barrier function are associated with reproductive and metabolic defects in women with polycystic ovary syndrome (PCOS): a pilot study.
- Torres Pedro J at al. Gut Microbial Diversity in Women With Polycystic Ovary Syndrome Correlates With Hyperandrogenism. J Clin Endocrinol Metab. 2018 Apr; 103(4): 1502–1511.
- Liu R at al. Dysbiosis of gut microbiota associated with clinical parameters in polycystic ovary syndrome. Front Microbiol. 2017;8:324.
