PCOS

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Polycystic ovaries is a condition whereby instead of a normal follicle developing each month (the capsule containing a developing oocyte/egg), the follicle does not develop properly. Because oestrogen is produced by the follicle, this means that there are lower levels of oestrogen produced and new production is irregular. This therefore can result in an erratic rise and fall in oestrogen levels resulting in irregular menstrual bleeds/periods.

Whilst ovulation (release of the egg/oocyte) can occur on some cycles, generally anovulatory cycles will occur either on most, or at least some, of the cycles in which case fertility can naturally be impaired. 

Symptoms of PCOS can include low oestrogen symptoms - falling or persistently low levels of oestrogen result in excess adrenaline release including flushes during the daytime and sweats at night, along with excess anxiety/heart racing/ feelings of being wired or excess adrenaline production. This will then impact on the ratio of deep-light sleep and there will be early morning fatigue. The mood can naturally be affected due to the falling oestrogen levels which effect serotonin metabolism (the mood hormone). Many of these symptoms worsen premenstrually when the oestrogen levels fall further.

Other symptoms include weakening collagen (stiff joints, dry eyes, thinning skin), bladder irritability symptoms and leakage, poor blood flow symptoms including loss of memory and concentration, headaches and leg cramps and vaginal dryness and loss of sex drive.

The failure of development of a large follicle also coincides with the formation of multiple small follicles/cysts and these produce androgens – male hormone. This can result in symptoms such as increased acne – facial and on the trunk, increased body and facial hair and thinning of scalp hair. Normally, oestrogen produced from the ovaries has a blocking effect on circulating androgens so if there is already inadequate oestrogen produced from the developing follicle as well as excess androgens from the tiny cyst/follicles in the ovaries, this will result in a high level of circulating androgens. These symptoms can be very distressing. 

Insulin is the hormone produced by the pancreas after eating which impacts on ovarian activity. High levels of insulin due to a genetic tendency towards insulin resistance, high carbohydrate and sugar diet both recently and previously as well as other body stresses such as chronic illnesses and medications such as progestogens, betablockers and antidepressants can all worsen insulin resistance.

Excess insulin production effects the normal development of the follicles so instead of good levels of oestrogen being produced by the developing follicle, the follicles will be small and the cycle will become erratic. 

In the longer term, excess insulin production leading to insulin resistance has adverse effects – see Insulin Resistance. 

The basis of treating PCOS  is to reduce insulin resistance and encourage normal development of the follicles. Naturally hormone levels will correct and the levels of androgens in relation to oestrogen will subside. 

In the shorter term however, supplementing the oestrogen levels until the normal follicular activity resumes can significantly help with many of the symptoms particularly vasomotor and mood. Using a natural oestrogen such as transdermal oestrogen gel, patches and also oral oestradiol can reverse many of the short term symptoms and adding in cyclical progesterone can regulate the cycle until the ovulatory process recommences.

How to treat background insulin resistance that leads to PCOS

1) Dietary changes – adhering to a low carbohydrate diet with two or maximum solid protein and low carbohydrate meals per day with no snacks will discourage excess insulin production and insulin resistance. The first meal of the day in particular must contain solid protein; starchy foods which can quickly disrupt the gut bacteria and stimulate insulin release should be avoided. These include cereal, porridge, granola, smoothies, fruit, yoghurt or any starchy or liquid forms of starch on their own as these will, on an empty gastrointestinal system, cause a high level of insulin production which will then take many hours to normalise.

2) Improve gut health – taking oil on waking and before large meals has been shown to line the gut and stop the insulin spike after eating. This does not absorb and therefore does not impact on cholesterol levels – in fact, this is the mechanism which by having fish oils or olive oil in the morning reduces cardiovascular disease and metabolic risk in the long term. Probiotic capsules can also improve the gut microbiome.

3) Medications to improve the excess insulin spiking – Acarbose works at the gut stopping the early spike of insulin after eating. This is a prescribed medication previously used for diabetes and can safely be used in pregnancy.

4) Medications to improve insulin resistance – these include non-prescription treatments such as myo-inositol, berberine and turmeric. It is known that some B vitamins such as Vitamin B6 and B12 can also improve insulin resistance as can Vitamin D. 

Prescription medications include:

· Metformin – a long established treatment for PCOS; the reason being is that it improves insulin resistance in patients even if they have no obvious stigmata of PCOS but have symptoms and signs of underlying insulin resistance as above. In the long term, metformin in conjunction with a low carbohydrate diet has been shown to improve metabolic health, cardiovascular and cerebrovascular risk and reduction in neurodegenerative conditions and some cancers. In the shorter term, it can improve the development of the follicle and ovulatory quality.

· GLP analogues – semaglutide (Ozempic and Wegovy), tirzepatide (Mounjaro), liraglutide (Victoza) – these injectable treatments reduce insulin resistance in the short term more effectively than metformin alone and can also reduce the centralised weight and inflammatory and vascular symptoms. Sometimes these need to be used in conjunction with metformin as they have different modes of action. 

Many patients with PCOS find that a combination of different types of insulin sensitising medication including inositol, metformin and injections can help at least in the short term and then once ovulation has resumed, it may be adequate to continue with either metformin alone or just dietary intervention.