What is PCOS, really?
by Darcy A. Ries, ND
PCOS is one the most common endocrine disorders occurring in reproductive-age women. It causes hormone disruption in the body, affecting hormones such as testosterone and DHEA), insulin, LH (luteinizing hormone), FSH (follicle stimulating hormone), estrogen and progesterone. These hormonal disruptions result in symptoms such as irregular periods, acne, weight gain, excessive body hair growth, and infertility. The acronym itself stands for Polycystic Ovarian Syndrome, as another hallmark of the condition is that multiple cysts can develop on the ovaries.
When I was in naturopathic medical school, diagnosis was confirmed via the Rotterdam criteria, which required two of these three to be present: high androgen levels, ovulatory dysfunction such as missed cycles/irregular periods, and polycystic ovaries.
Of course, physicians recognize that not every woman with PCOS has these hallmark symptoms: for example, some may lack the presence of ovarian cysts, or not experience excessive hair growth, and today we recognize that PCOS can affect women of any body size.
But reviewing all the details thus far, all we’ve done is describe symptoms – we have not gotten to the nitty gritty of what PCOS truly is. What’s the underlying mechanism? Why do hormones get screwy in the first place?
The medical community seems to agree that there are certain conditions and presentations associated with PCOS: insulin resistance, elevated blood sugar levels or frank type 2 diabetes, obesity, high blood pressure, fatty liver disease, and elevated lipids. But the cause remains vaguely stated.
There is certainly a correlation between genetic factors and PCOS, suggesting that it can be an inherited condition. This is not necessarily news, as so many chronic diseases have a genetic component.
Research in the past few years has suggested that there may actually be distinct subtypes of PCOS, each with their own underlying mechanisms contributing to disease. One of these subtypes is thought to be more “reproductive” in nature, and the other more “metabolic” in nature.1
The reproductive subtype was correlated with certain genetic expressions that can cause functional defects in the ovaries, changing follicular development and altering hormone levels. This subtype demonstrated higher LH and SHBG levels, but relatively lower insulin and BMI (body mass index) levels.1
The metabolic subtype was correlated with certain genetic expressions that play a role in insulin receptor signaling and is associated with type 2 diabetes. This subtype demonstrated higher BMI, glucose, and insulin levels, but with relatively lower SHBG and LH levels.1
Considering that almost half of women suffering PCOS also develop type 2 diabetes, it is not surprising that one root cause of PCOS may actually be metabolic in nature. That it’s not PCOS causing metabolic dysfunction, but the other way around. As the body becomes resistant (less responsive) to insulin, this leads to higher insulin and glucose levels, thus fueling weight gain and promoting the overproduction of androgen hormones.2
Either way another important point to make is that these subtypes, while admittedly a super fun discovery by modern research, still put all the focus on genetics. While genes may be powerful, as a functional medicine practitioner I don’t see genetics as the final fate – the reality is that those genes need to be switched on in order to be expressed. Spoiler alert – this is largely invoked or avoided by environmental influences, most notably our lifestyle-dependent behaviors.
Modern medicine loves the shiny and heroic appeal of the lab or operating room. Genetics sounds both brainy and impressive. The approach of functional medicine is admittedly less flashy: supporting the body’s systems and improving lifestyle factors within our control can help us keep genetic predispositions in check. By understanding the underlying mechanism of a health challenge, such as PCOS, we can address the root cause. By going beyond band-aid approaches that just treat symptoms, we can move into the more holistic realm of supporting health.
If you have PCOS that has not been effectively managed with conventional care, consider alternative approaches such as naturopathic medicine, functional medicine by other appropriately trained clinicians, or Chinese medicine to support your health. As always, consult with your acting physician both before and throughout any alternative care sessions. The collaboration of your healthcare providers is key to safe and successful outcomes.
References:
- Matthew Dapas, Frederick T. J. Lin, Girish N. Nadkarni, Ryan Sisk, Richard S. Legro, Margrit Urbanek, M. Geoffrey Hayes , Andrea Dunaif. Distinct subtypes of polycystic ovary syndrome with novel genetic associations: An unsupervised, phenotypic clustering analysis. Plos Medicine. 2020 June 23 https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1003132
- Unluhizarci K, Karaca Z, Kelestimur F. Role of insulin and insulin resistance in androgen excess disorders. World J Diabetes. 2021;12(5):616-629. doi:10.4239/wjd.v12.i5.616 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8107978/
