PCOS is still not fully understood, and I for one, am NOT an expert. This is a collection of evidence from the literature and people I respect highly on the subject.
PCOS is a heterogenous, multifaceted and complex disorder associated with metabolic and hormonal impairments, ovarian dysfunction, menstrual irregularity and infertility. PCOS affects 6-21% of women of reproductive age dependant on the criteria. Not only is it heavily linked with infertility, but has been associated with increased risks of type 2 diabetes, hyperplasia and cancer in the uterus.
Diagnosis of PCOS is regarded as 2 of 3 potential causes: i) Increase in male hormone levels ii) Polycystic ovaries iii) Altered menstrual cycle. PCOS can be characterised in 3 ways;
- Reproductive were menstrual cycle and high prevalence of male hormone levels can lead to increased infertility or pregnancy complications
- Metabolic, insulin resistance increases the risk of diabetes and cardio vascular disease
- Psychological, increased anxiety, depression and quality of life
So PCOS can be quite devasting, but how do we put things in place to start to combat it.
We want to reduce insulin resistance. Insulin resistance leads to increase blood glucose (not good) and then a hyperinsulinemia (too much insulin), this then leads to an increase in ‘male hormone’ (testosterone) profile. So how do we increase insulin sensitivity (the opposite of resistance).
Firstly, the role of low glycaemic index (GI) has shown great improvements improving menstrual regularity, reductions in insulin resistance, total, and HDL-C (high density lipoprotein cholesterol). A low GI diet composes of foods that dampen the insulin response, using the glycaemic index itself we can choose foods that sit at the lower end of the scale to make more sensible choices to reverse insulin resistance.
Secondly a high protein diet has been shown to decrease depression symptoms and improve self-esteem within participants. PCOS sufferers exhibit a higher protein oxidation (breakdown) rate whilst fasting overnight. Therefore, a higher protein intake will help offset some of this oxidation, alongside protein having a higher satiety than other macronutrients to help stay fuller for longer allowing for weight loss to occur. High protein diets, may also result in minor endocrine (hormone) and metabolic improvements, however, as previously stated we know that high protein diets work for fat loss and a drop of weight by as little as 5% was enough to report increased outcomes of PCOS. High protein diets provide improvements in appetite, body-weight managements, cardio-metabolic risk factors or all of the above factors.
The role of fruit, fruit is high in fructose which does not require insulin to be released for it to be absorbed, fructose is absorbed rapidly within the liver. Fructose can improve glucose tolerance as it doesn’t spike insulin to be absorbed. However, excess fructose may cause negative health outcomes that exacerbate PCOS. Because of fructose lipogenic (fat storing) properties, this excess fructose can cause glucose and fructose malabsorption, and elevations in triglycerides and cholesterol. The overproduction comes from fructose’s ability to enter glycolysis (carbohydrate metabolism) freely without regulation, unlike glucose.
Nutritional strategies need to be strict, unfortunately.
A period of intense experimentation and recording needs to happen, for you to fully get to grips with your body and how it is working.
It’s very psychologically demanding, so if you’ve been dieting (successfully or not) you may find it tough going, and may need to take a break from dieting before starting it. This however needs to be done under supervision of a professional, or at least someone who understands PCOS and the steps needed to be taken to help offset its side-effects.
Metabolic adaptation.
Unfortunately, we know that weight loss can significantly improve PCOS outcomes, its not as simple as a calorie deficit in these cases. PCOS sufferers has been shown to have a blunted thermogenesis, meaning that they may need less calories to survive. Within females with PCOS and insulin resistance, this adaptation could be a big as 40%, that’s huge. For example, if your maintenance calories were 2000, this situation would mean that drops to 1200, which is NOT a lot of food. Further to this, to then lose body fat, and become in a calorie deficit, you may need to eat less than this, and even then progress would be slow. This unfortunately is a harsh reality, that comes with PCOS, however, with some of the methods of improving insulin sensitivity, this should hopefully slowly elevate those maintenance calories, in turn aiding fat loss.
Training strategies.
Weight training is a key player in PCOS as it has a huge role to play in reversing insulin resistance. When your muscle cells become insulin resistant, it means that the glucose transporter (GLUT 4) within the cell is not mobilised when insulin is present. However, weight training also stimulates the movement of this transporter to the cell membrane where it can collect the glucose from insulin, helping to reduce blood glucose levels and also utilise glucose as a fuel source through training. Both of these impact insulin sensitivity and fat loss.
The emphasis on compound lifts cannot be understated in this, as you will get more bang for your buck in regards to glucose uptake.
Supplementation for PCOS.
Omega-3 Fatty acids.
When taken as a healthy individual, omega-3 does not affect insulin sensitivity, however when 1.2g (EPA & DHA) daily is taken, lipid (fat) profile, insulin resistance and serum adiponectin levels all improved and androgen hormonal profile improved in PCOS patients following supplementation. A recent meta-analysis cocluded that omega-3 exerts multiple benefits to PCOS women, including, anti-obesity, glycaemic and hormonal homeostasis (balance), anti-inflammatory properties and many more complex processes, this was using 1.5g of omega-3 (DHA & EPA).
Vitamin D.
Vitamin D is heavily linked to insulin sensitivity, which would in turn improve insulin resistance in PCOS women. However, vitamin D deficiency is common across PCOS affected women, and are causally related to the hormonal and metabolic impact of PCOS. Whilst it is yet not fully understood if; 1) PCOS causes a dysfunction of VitD metabolism, or: 2) VitD deficiency is a cause of PCOS. Typically, we need more research on the relationships between VitD and PCOS, nevertheless there is a relationship between the two, despite not knowing precisely which is the primary factor.
It’s difficult to put a value on how much VitD you should be having, it would be best to get checked with your doctor to see current levels and let them advise a decision based on this.
Carnitine
L-Carnitine have immense functional capabilities to help regulate the oxidative and metabolic status of the female reproductive system. The use of carnitine is thought to protect the reproductive cells from oxidative damage and to better regulate hormones. A study in 2016, supplemented with 250mg of L-carnitine in 60 overweight PCOS women. In 12 weeks, weight was reduced by 2.7kg versus the placebo, waist circumference was reduced by 2cm versus 0.3cm loss, hip circumference was reduced by 2.5cm versus 0.3cm. On top of these physical changes, fasting plasma glucose and serum insulin levels were both reduced. Like anything in this blog, please get advice from a professional.
Inositol
Inositol’s are a group of natural sugars (polyols), belonging to a class of compounds called cyclohexanols, found predominately in fruits, beans, grains and nuts. Inositol acts as a secondary messenger for insulin, participating in insulin dependent processes, one of which is cellular glucose uptake, which would help reduce hyperinsulinemia (too much insulin).
Inositol use reduces the level of free testosterone (an androgen), which presence exacerbates PCOS symptoms. One study found a reduction of free testosterone from 96.6ng/ml to 43.3ng/ml, and progesterone rose from 2.1ng/mL to 12.3ng/mL when supplemented with inositol and folic acid. Inositol in gelatine capsule form is much more bioavailable and therefore the dosage doesn’t have to be as high (vegans will need to use powder). Inositol increases insulin sensitivity, not only increasing the effectiveness of fat loss within the PCOS, but also increases the outcomes of pregnancy in relation to gestational diabetes.
Whilst evidence is still been found for the use of inositol, it may be beneficial in the outcome of PCOS, again, seek professional advice.