Podcast with Dr Fiona McCulloch, ND
*For a downloadable copy click on this link: download here
The basic definition is an endocrine disorder, it’s not really about the cysts on the ovaries. It is characterised primarily by insulin resistance or the secretion of too much insulin and secondly androgen excess, hormones like testosterone.
Some symptoms Fiona describes in her personal journey were cystic acne where she tried treating with everything but nothing would help, periods that were very far apart – 3 to 4 per year and insulin resistance, gaining weight around her stomach. After finishing school, she got the testing she needed and found out she had a lot of the blood markers for PCOS.
According to an article on Fiona’s website approx. 50% of women who have PCOS don’t know they have the condition.
Fiona’s advice is to get the right testing at the right age, as it can vary. A couple of tests that are helpful is on Day 3 of your cycle ask for FSH and LH, often the LH will be double the FSH, you can also check on some of the androgens such as testosterone or DHEA-S. Some other signs are acne, hair loss at the front of the hairline, hair growth on their chin (which they may have but their testosterone looks quite normal). One of the tests that are quite sensitive is AMH (antimullerian hormones) as that hormone does tend to be high – again this is an age-related hormone, so the older you get the lower it gets. Comparing what is normal for your age is a good indicator.
By visiting Fiona’s website https://drfionand.com/ she has a lab guide that goes through the age-related range which you can download. It also shows all of the different lab tests that can be ordered for PCOS and what cycle day to take them on as well as what is considered normal.
Other testing is for insulin resistance. This wouldn’t necessarily pick up PCOS because women can have insulin resistance without PCOS but there are some tests that can be done that are not usually ordered, like fasting insulin and fasting glucose together or the fasting glucose tolerance test. This test is almost like the glucose test but insulin is added in, abnormalities are often seen there.
Really the big signs are the symptoms, long cycles (not just the bleeding, the entire cycle), cycles that are longer than 33 days consistently for any length of time, especially when you were younger, and as we mentioned before, the jawline hair growth and hair loss at the front of the hair.
You can also ask for a transvaginal ultrasound to check for signs of cysts around the outer part of the ovary. These do tend to resolve with age for many women. If a women doesn’t have cysts but has all the other signs of PCOS then this is more important for treatment.
Lean women are the sector that gets missed the most as MD’s don’t see them as having PCOS due to the different presentations at different times in a woman’s life. A woman who is a runner may not present the same way, due to weight loss, as opposed to a woman who went on to become pregnant and puts on 20lbs. Research shows that the lean women do have insulin resistance it’s just not easy to pick up and definitely not easy to pick up with the commonly ordered tests.
A lot of the time doctors will order HbA1C (Hemoglobin A1C) testing or fasting glucose and those tests will come back normal and the women looks lean so they will say she doesn’t have any insulin resistance but what Fiona finds in her clinic is that the fasting glucose challenge the lean women secrete a lot more insulin after the glucose drink than other lean women.
If you can address just the one factor of insulin resistance that makes a big difference, it changes everything and it’s the most important thing. By dealing with the insulin resistance it also addresses the other chronic risks that are associated with PCOS. Also addressing what is important to them, acne, losing a lot of hair, then we can start focusing on their goals and what is stressing them out the most about PCOS.
With regard to insulin resistance and nutrition, what are your suggestions? It varies for each client but Fiona uses the Food Insulin Demand, we have information on how much insulin we need to process a given food so she bases a meal plan on keeping their insulin secretion controlled after they eat, and also keeping their blood sugar balanced. A lot of women who have PCOS have a lot of trouble keeping their blood sugar stable. They have high insulin which causes their blood sugar to go into a roller coaster phase where it goes up and down, the only solution for low blood sugar is to eat sugar and carbs, so a big factor is keeping blood sugar balanced. Also following a more anti-inflammatory approach, cutting out dairy, wheat and added sugar.
PCOS treatment is a long game, women don’t usually have good sensitivities so being super strict on your diet is not as important as keeping your blood sugar stable so you can eat well for the rest of your life.
Women with PCOS tend to go through menopause later in life, mostly because they have more eggs in their ovaries but also more testosterone. Women in menopause may think that because the ovaries are quiet that the PCOS has gone, but that is not the case, all the research shows that it is still there. Insulin resistance actually gets worse so women with this condition are much more prone to adding weight around the middle, getting type 2 diabetes and cardiovascular disease. It is even more important to focus on your PCOS as you go through menopause and know how to eat because it is really not a reproductive disorder as is commonly thought. It really is an endocrine disorder with insulin resistance and a tendency to develop type 2 diabetes.
Would high DHEA be a predictor of a “quieter” menopause? Fiona believes those women who do have higher DHEA levels (not all women with PCOS do) experience a more relaxed menopause. As menopause comes later for women with PCOS and it’s a little easier, they can also retain more muscle mass and bone density.
PCOS remained in our genetics for a reason, it makes women less fertile. The reason for the gene is it helps you survive famine, the women who had more fat stores during a famine would survive to then bear children later on. When we think about this, women who have PCOS have really smart metabolisms and always find a way to store energy, hence why it can be very frustrating for women who try every kind of diet and nothing seems to help them lose weight.
Eventually, the diets just stop working as their metabolism says “nope we are not doing that” and it just goes on to store energy (as fat).
Fiona suggests eating a certain way “most of the time” but then switching it up, keeping the metabolism guessing. If you keep to the same diet repeatedly the body will get smart to that. So definitely intermittent fasting (IF) or time-restricted eating can be beneficial. Eating within a certain window, then you’re getting a longer time without insulin release so your cells become more insulin sensitive. Other suggestions might be 2 days on a lower calorie program and then 5 days higher calorie, just switching it up is really helpful.
There is also the Fasting Mimicking Diet which is really low calorie for 5 days, trying different ways to eat always bearing in mind you want to keep your insulin levels controlled. Keto can work for some women but Fiona recommends that more of a last resort because it causes low insulin all of the time, which is not the goal, the goal would be to have normal insulin after we eat and not just flat line insulin because insulin does have roles within our health and within our bodies. But for those women where that is the only way to eat and that works, then that is great for those women as it is a tough condition to deal with, with regard to diet.
Exercise is really important to women with PCOS, more than for many other conditions because it increases insulin sensitivity and the more muscle mass you can build the more insulin sensitive you will be which is also beneficial. Strength training or high-intensity exercise is always really helpful, like HIIT training for 20 mins is ideal.
Stress can affect PCOS quite heavily, particularly is the women has the adrenal, androgen type of PCOS. For this type, stress will actually raise the number of androgens in the body. We also know that not getting enough sleep causes more insulin resistance and weight gain so stress reduction is definitely a huge part of working with women with the condition.
Leptin resistance and PCOS. Leptin is a hormone secreted by our fat cells and it basically tells us that we have had enough to eat. When you are insulin resistant, you also become leptin resistant, it causes the signs that you are full to not exist and be totally messed up.
A lot of women with PCOS have trouble telling when they are hungry and when they are full. There are a lot more problems with bingeing and that then contributes to the insulin resistance, causing weight gain and blood sugar issues. It’s like a cycle where everything in the whole body and the brain is impacted.
Excessive facial hair and signs of androgens and how to approach this beyond nutrition. Outside of nutrition (that obviously plays a role), hirsutism can be a really big problem, once the hair has started to grow there is nothing you can do besides have it removed via laser therapy or electrolysis. There are some other things you can do that will actually reduce the growth of the hair or make it less thing such as spearmint tea. Take 3 tea bags, fill a French press or tumbler with hot water and steep, then drink throughout the day, most women will see a reduction. This can also work for women with acne if it is hormone related.
With regard to acne, if they haven’t been ovulating as regularly and then they start to, their acne will get worse, so we are improving their hormones but now their acne has increased. For acne, you have to break the cycle so a combination of topical and also internal treatments. When it first starts to break out, spearmint tea likely wouldn’t be enough to deal with the inflammation but it would definitely help with the androgen levels and the effect on the skin.
Using tea tree oil on the skin can also help in the first stages and a mild exfoliator for the skin, like an alpha hydroxy acid to stop the blockage of the pores topically.
Another favourite is N-acetylcysteine that is a supplement which is an anti-oxidant which improves the integrity of the skin, reduces inflammation and is a great supplement for all the different elements of PCOS but especially for acne.
Sleep and sleep apnea. Sleep apnea is very common in PCOS and the incidence of it goes up the more abdominal fat you are carrying. The number one thing to do is work on the insulin resistance and getting that abdominal fat burned.
The good thing is that when you come out of insulin resistance the abdomen is the first place the fast will come off. A lot of the time, if you can reduce your waist circumference by just 2 inches that’s going to do a lot for sleep apnea. Don’t worry about the number on the scale, but measure your waist, that’s the most important thing to look at if you are wanting to track your progress.
High insulin stops us from burning fat and it makes us store fat, so by getting your insulin under control, that fat is the first place it’s going to come off.
If you are obese, it’s going to take a lot longer to lose the belly fat. Our brains change once we have been carrying the weight around for a while. When there is a lot of excess weight, the insulin resistance continues and so for some, they find the Ketogenic diet helpful because it definitely lowers the insulin and that’s the only thing that will lower it but everyone is a little bit different. If the person is able to exercise, put on some muscle mass, fast with medical supervision they can reset their body set weight, it might not be their ideal but it’s going to be a lot better. For 20 plus years it’s going to be a lot harder to stick to a new regime but if it’s been 2-3 years you will see improvements fairly quickly and go right back to being lean.
It takes a lot of patience and not comparing yourself to anyone else, to see yourself as where you were to where you are now as such an improvement can really help make the journey easier.
Top 3 tips:
Go and have the Insulin Glucose Challenge Test – see Fiona’s website for an article on this particular test. It will give you a good baseline as to where you are when you are starting.
Make sure your meals have protein, lots of vegetables and food sources of healthy fats, olives, avocados, nuts and seeds. Keep the carbohydrates under control at each meal, a smaller amount.
Exercise, especially strength training, not only for women with PCOS but to keep our bone density optimal and to retain muscle mass in perimenopause.