Polycystic Ovary Syndrome (PCOS)
Last updated: May 2020
Originally published: October 2019
Our science and research team launched goop PhD to compile the most significant studies and information on an array of health topics, conditions, and diseases. If there is something you’d like them to cover, please email us at [email protected]
Polycystic Ovary Syndrome (PCOS)
Last updated: May 2020
Originally published: October 2019
Our science and research team launched goop PhD to compile the most significant studies and information on an array of health topics, conditions, and diseases. If there is something you’d like them to cover, please email us at [email protected].
Understanding Polycystic Ovary Syndrome (PCOS)
Polycystic ovary syndrome is a hormonal disorder that affects women of reproductive age. It is characterized by irregular menstrual periods, excess male hormones, and/or ovarian cysts.
Until we’re postmenopausal, most women get their period every twenty-eight days or so, and it typically lasts anywhere from four to seven days. But women with polycystic ovary syndrome (PCOS)—a common hormonal problem that affects up to one in ten women—may skip their period or experience longer periods. Other symptoms of PCOS include acne, excess hair growth (hirsutism), weight gain, pelvic pain, irregular periods, depression, ovarian cysts, and infertility (Bozdag, Mumusoglu, Zengin, Karabulut, & Yildiz, 2016). Given the symptoms and how common PCOS is among women, it is fairly under-studied. But there is a meaningful collection of research on lifestyle changes, medications, treatments, clinical trials, and other interesting studies that can help us navigate PCOS.
How Many Women Have PCOS?
Polycystic ovary syndrome (PCOS) affects one in ten women, but many aren’t aware that they are affected by it.
Hormone Imbalance and Ovarian Cysts and Follicles
Women have two ovaries with two crucial reproductive jobs. Our ovaries release eggs during our menstrual cycle and they also produce three major hormones—estrogen, progesterone, and testosterone—as well as a few other hormones, like inhibin and relaxin. The “female” hormones estrogen and progesterone are necessary for the menstrual cycle. The “male” androgen hormones, like testosterone, are also needed at low levels in women, although the reasons why are not entirely clear. One theory is that testosterone is related to female sexual desire and lubrication (Davis & Wahlin-Jacobsen, 2015). Women with PCOS often have higher than normal levels of testosterone and low levels of estrogen, creating a hormone imbalance that interferes with ovulation and can manifest as ovarian cysts (Housman & Reynolds, 2014).
Ovarian cysts are very common. They’re typically small, unnoticeable fluid-filled sacs that don’t cause problems; many of us have had or will have one in our lifetime, usually without knowing it. Cysts become an issue if they grow to be large and painful or if multiple cysts grow on the outer edge of the ovaries, as is often the case in PCOS. It’s also possible for women to have ovarian cysts due to other conditions, such as endometriosis. But what distinguishes PCOS from other conditions is the hormonal imbalance. Another technicality is that women with PCOS actually have ovarian follicles, not ovarian cysts. Which means: Follicles and cysts look exactly the same on ultrasound, and while the names are used interchangeably, follicles contain an immature egg, but cysts do not. Since women with PCOS have trouble releasing an egg each month due to hormone imbalances, these follicles tend to build up on the ovary over time. This is sometimes described as looking like a “string of pearls” on the ultrasound (Housman & Reynolds, 2014).
Potential Causes and Related Health Concerns
The exact cause of PCOS is not known. It runs in families, so it is likely caused by a combination of genetics and environmental factors. One factor that has been heavily researched is insulin resistance.
Insulin Resistance, Weight, and Diabetes
Women with PCOS have a high prevalence of insulin resistance, regardless of their weight. They also have a higher risk for other diseases, such as diabetes and cardiovascular problems, especially if they are overweight (Bil et al., 2016; Jeanes & Reeves, 2017).
How Does Insulin Work?
Insulin helps our body regulate the amount of sugar in our blood. In the case of insulin resistance, the body’s cells don’t respond to insulin very well, which causes your blood sugar level to rise. And your body compensates by making more and more insulin.
This can eventually progress to diabetes. Scientists aren’t sure whether PCOS causes insulin resistance or insulin resistance causes PCOS (more on this later in our research section).What we do know is that insulin resistance can cause issues such as type 2 diabetes, metabolic syndrome, and cardiovascular disease if not managed properly. It’s also been linked to increased cancer risk (Orgel & Mittelman, 2013).
The risk of type 2 diabetes may be up to four times greater and diagnosed an average of four years earlier among women with PCOS compared to other women (Rubin, Glintborg, Nybo, Abrahamsen, & Andersen, 2017). In addition, women with PCOS are more likely to be obese, with one meta-analysis estimating the risk of obesity is almost three times higher among women with PCOS (Lim, Davies, Norman, & Moran, 2012). The weight gain with PCOS can be stubborn due to the underlying hormonal issues. Insulin resistance and diabetes are huge risk factors for heart disease if not properly managed.
For women with PCOS, figuring out how to balance insulin levels through lifestyle changes is incredibly important for managing PCOS symptoms and for preventing potentially more serious issues down the road.
Fertility and PCOS
In addition to irregular periods and ovulation issues, infertility is relatively common in women with PCOS, which can be heartbreaking for those who want to become pregnant. There are many medications and technologies available today (and more likely coming) for women who struggle with fertility issues. Losing weight, if you’re overweight, can be a first step to help with ovulation and fertility (Morgante, Massaro, Di Sabatino, Cappelli, & De Leo, 2018). Fertility medications such as clomiphene citrate (aka Clomid) increase hormones to support ovulation. They can be taken alone or in combination with metformin (ASRM, 2017; Morley, Tang, Yasmin, Norman, & Balen, 2017); read more under the conventional treatments section. Other, more aggressive treatment options you may want to discuss with your doctor include assisted techniques such as in vitro fertilization (IVF), bariatric surgery for weight loss, or laparoscopic ovarian surgery (Balen et al., 2016; Butterworth, Deguara, & Borg, 2016). If you have been diagnosed with PCOS and plan to become pregnant, discuss fertility screening and treatment options with your doctor.
Mental Health and PCOS
Many women with PCOS struggle with mood disorders, such as depression and anxiety, which are likely connected to PCOS-related hormonal issues. If you’re struggling: You’re not alone. And there are treatment options that can help. If you are in crisis, please contact the National Suicide Prevention Lifeline by calling 800.273.TALK (8255) or the Crisis Text Line by texting HOME to 741741 in the United States.
In numerous studies, exercise has been shown to improve quality of life among women with PCOS. In one study, an eight-week mindfulness stress-management program was shown to reduce stress, anxiety, and depression among women with PCOS (Stefanaki et al., 2015). There is currently a clinical trial recruiting for depression treatment among women with PCOS; for more information, see our clinical trials section below. Learn more about how to get help with mental illness here.
A large Swedish study of 4 million women looked at cancer risk among those who were diagnosed with PCOS. These women had significant risk for cancer of the pancreas, kidneys, endocrine glands, endometrium, ovaries, skeletal system, and blood. More specifically, the researchers found that this cancer risk was higher across the board among premenopausal women (Yin, Falconer, Yin, Xu, & Ye, 2018). A leading scientific theory is that increased insulin, blood sugar, and inflammation contribute to cancer initiation and progression (Orgel & Mittelman, 2013). Thus, it’s recommended that women with PCOS routinely screen for cancer while working to normalize their blood sugar, insulin levels, and weight to reduce risk factors.
How PCOS Is Diagnosed
There’s not a single test to identify PCOS, which can make diagnosis difficult and sometimes confusing, even for doctors. Women with PCOS are often left out of the medical narrative and can be overlooked or diagnosed with other, more commonly researched diseases. One study of women in Australia showed that almost 70 percent of the women who had PCOS had not been previously diagnosed before the study (March et al., 2010). While there has been debate over the most clinically relevant criteria for PCOS diagnosis, the Rotterdam Criteria (Goodman et al., 2015) is the most widely recognized by doctors and researchers.
The Rotterdam Criteria
According to the Rotterdam Criteria, diagnosing PCOS relies upon the presence of two out of three key symptoms: irregular periods (or no period at all), high levels of testosterone, and/or polycystic ovaries (Rotterdam, 2004). So you don’t necessarily need to have polycystic ovaries to be diagnosed with PCOS, which makes the name a misnomer.
Doctors may order blood tests to determine your hormone levels in addition to an ultrasound or a pelvic exam. Testing for free testosterone is essential for the diagnosis, while progesterone and anti-Müllerian hormone levels can also be helpful. Physicians will want to rule out other conditions, especially among younger women, as irregular periods and acne may just be a normal part of puberty. Early diagnosis of PCOS is key for normalizing menstrual cycles and protecting against related risks, such as infertility, diabetes, and cardiovascular disorders. Women should create a plan with their doctors to address individual needs, depending on factors such as weight and whether they plan to have children. Endocrinologists (hormone experts), particularly reproductive endocrinologists, and ob-gyns are the specialists who are best qualified to advise on the specifics and tailor a treatment plan to your hormonal needs.
Simple lifestyle changes—healthy diet and exercise—can assist with weight loss, PCOS symptoms, and fertility, while also working to reduce risk of other diseases in the long term, such as type 2 diabetes and heart disease.
Weight loss is often the first line of defense. If you are overweight, losing as little as 5 percent of your weight can improve metabolic and reproductive abnormalities as well as risk for other long-term issues (Stamets et al., 2004). Numerous studies have shown that lifestyle modifications (exercise and diet changes) are effective at improving insulin resistance, hormone levels, and weight loss in women with PCOS (Haqq, McFarlane, Dieberg, & Smart, 2014; Moran, Hutchison, Norman, & Teede, 2011). Other studies have shown that lifestyle changes in combination with medications are more effective than medications alone (Legro et al., 2015; Naderpoor et al., 2015).
There has not been a general consensus on the best diet for women with PCOS. Most studies base their recommendations on diets for individuals with type 2 diabetes. Good results have been shown for diets that are low-carb, low-GI, and high-fiber, but more large-scale research is needed.
Low-Carb, Low-GI Diets
Foods containing carbohydrates can be defined by their glycemic index (GI), which is a measure of how quickly they raise the sugar (glucose) level of the blood. High-glycemic diets have been shown to be associated with both PCOS and obesity (Eslamian, Baghestani, Eghtesad, & Hekmatdoost, 2017; Graff, Mário, Alves, & Spritzer, 2013). On the other hand, several studies have shown that low-carb and low-GI diets can decrease insulin levels and improve insulin sensitivity in women with PCOS (Barr, Reeves, Sharp, & Jeanes, 2013; Berrino et al., 2001; Douglas et al., 2006; Marsh, Steinbeck, Atkinson, Petocz, & Brand-Miller, 2010).
Picking carbs that have a low GI, such as vegetables, whole grains, and legumes, can reduce your blood sugar spike after a meal and can reduce insulin resistance (Brand-Miller, Hayne, Petocz, & Colagiuri, 2003). Studies have also found that low-carb diets can help with weight loss in women with PCOS (Berrino et al., 2001; Goss et al., 2014; Marsh et al., 2010). They also may be able to help with menstrual regularity, although more research is needed (Marsh et al., 2010). One thing to keep in mind: Low-carb is different from a ketogenic diet, which is low-carb and high-fat (more on dietary fats and PCOS below).
High-fiber diets may be beneficial. While fiber is molecularly a carbohydrate, it is unlike other carbohydrates in that it does not get digested as it passes down your digestive tract and therefore does not affect your blood sugar levels in the same way that other carbs do. Foods that contain a lot of fiber have a low GI. Diets high in fiber have been shown to help overweight individuals with a high risk of type 2 diabetes lose weight. Furthermore, research has shown an association between low-fiber diets and PCOS (Eslamian et al., 2017).
There hasn’t been much research assessing high fiber diets for women with PCOS, but one study found that women with PCOS who reported eating more fiber showed less insulin resistance and had less total body fat (Cunha, Ribeiro, Silva, Rosa-e-Silva, & De-Souza, 2018). Another study showed that high fiber and low trans-fatty acid intake were associated with metabolic improvements among overweight women with PCOS (Nybacka, Hellström, & Hirschberg, 2017). ). And a third, more recent study found published in 2019 found that lower testosterone levels were associated with increased fiber intake among women with PCOS (Barrea et al., 2019). Overall, high-fiber diets seem promising for PCOS, but more research is needed.
Which Fats to Eat
Some diets targeted at weight loss will suggest that you lower your fat intake, but whether this is effective really depends on what kind of fat we’re talking about. You’ve probably heard of “good” fats, like monosaturated fat and polyunsaturated fat, and “bad” fats, like saturated fat and trans fat. Saturated fat increases blood cholesterol and has been shown to be associated with metabolic syndrome, so women with PCOS who have insulin sensitivity should lower their saturated fat intake by cutting out high-fat dairy (butter, pastries, ice cream) and fatty meats (marbled steak, lamb) (Riccardi, Giacco, & Rivellese, 2004). The US Food and Drug Administration has taken steps to reduce the amount of trans fat in processed foods, but avoiding processed foods is still generally a good idea. If you’re cutting out carbs like high-GI foods, sugars, and white flour, try substituting with healthy fats, like oils and nuts, in addition to protein, vegetables, whole grains, and legumes.
The DASH Diet
The Dietary Approaches to Stop Hypertension diet, aka the DASH diet, has been shown to be helpful for weight loss as well as for reducing insulin and androgen levels in women with PCOS. It consists of low-GI, high-fiber, and low-calorie meals rich in fruits, vegetables, whole grains, and low-fat dairy. It was originally designed for individuals with high blood pressure, but a couple of randomized controlled trials have demonstrated benefits for overweight women with PCOS.
The first study, in 2014, showed that overweight women with PCOS who followed the DASH diet for eight weeks lost weight and had significantly lower insulin (Asemi et al., 2014). A second study of overweight women with PCOS showed that eating the DASH diet for twelve weeks improved weight loss while reducing BMI, fat mass, and androgen levels (Azadi‐Yazdi, Karimi‐Zarchi, Salehi‐Abargouei, Fallahzadeh, & Nadjarzadeh, 2017). You can find a sample menu of the DASH diet online.
The Research on Dairy
So what about dairy? The DASH diet emphasizes low-fat dairy, but another study suggests that eating less dairy could be beneficial. Eating a diet low in dairy for eight weeks was shown to reduce weight, insulin resistance, and testosterone levels among women with PCOS (Phy et al., 2015). This diet included lean animal protein, fish and shellfish, eggs, nonstarchy vegetables, low-sugar fruits, nuts and seeds, oils (coconut and olive), and a small amount of red wine and full-fat cheese per day. (Yes, just a little bit was allowed so people would actually stick to the diet.) The diet excluded grains, beans, other dairy products, and sugar.
Nutrients and Supplements for PCOS
Women with PCOS may benefit from supplementing with vitamin D and omega-3s. But other nutrients may have adverse health effects.
Some women with PCOS are deficient in vitamin D, and women with PCOS who are overweight are even more severely deficient (Hahn et al., 2006; Yildizhan et al., 2009). Vitamin D deficiency may also exacerbate symptoms of PCOS such as excess hair growth (hirsutism) and insulin resistance, as well as increase risk for cardiovascular problems and miscarriage, which may be of special concern for women with PCOS due to coexisting reproductive issues (Hahn et al., 2006; McCormack et al., 2018; Thomson, Spedding, & Buckley, 2012). A 2020 meta-analysis of eleven studies found that vitamin D supplementation among women with PCOS was associated with significantly decreased testosterone levels, insulin resistance, and cholesterol levels, but did not have a significant effect on BMI (Miao et al., 2020). The studies included in this meta-analysis each used differing doses for vitamin D for different periods of time, so future well-controlled studies are needed to determine what dose of vitamin D is beneficial for women with PCOS. Another study published in 2020, after this meta-analysis, found that 10,000 IU of vitamin D twice weekly combined with clomiphene citrate and calcium may improve ovulation among women with PCOS (see here for more on fertility and PCOS) (Rasheedy et al., 2020). You can get only a small amount of vitamin D from your diet, so sunshine and supplementation are often important.
Good or bad? Chromium is a trace mineral that is needed for cells to respond to insulin and remove sugar from the blood. Type 2 diabetics have been shown to have low chromium levels, which suggests that chromium may play a role in insulin resistance, which is common among women with PCOS (Morris et al., 1999). On the positive side, chromium picolinate supplementation has been shown to reduce blood sugar and insulin levels in women with PCOS at doses of 200 to 1,000 micrograms (Amooee, Parsanezhad, Shirazi, Alborzi, & Samsami, 2013; Lydic et al., 2006). Furthermore, 200-microgram chromium supplements were shown to help with a wide array of PCOS symptoms such as acne, hair growth, and inflammation in one clinical trial (Jamilian et al., 2016).
Here’s the downside: A recent meta-analysis of six randomized controlled trials found that while chromium-treated patients had decreased insulin, they also had increased testosterone, so chromium supplementation may not be ideal for women with PCOS (Tang, Sun, & Gong, 2018). If you take a multivitamin or supplement with chromium, keep in mind that it may affect your testosterone levels.
Selenium is key for our body’s main antioxidant, glutathione. Low selenium levels may be related to higher testosterone levels among women with PCOS (Coskun, Arikan, Kilinc, Arikan, & Ekerbiçer, 2013). Several studies among Iranian women have assessed the effects of selenium supplementation with differing results. Two studies reported benefits with 200 microgram supplements, but one reported worsening of insulin resistance at the same dose, so more research is needed to determine whether selenium supplementation is a good idea (Jamilian et al., 2015; Mohammad Hosseinzadeh, Hosseinzadeh-Attar, Yekaninejad, & Rashidi, 2016; Razavi et al., 2015).
Omega-3 fatty acids are essential nutrients that are found in fish, flaxseeds, chia seeds, and walnuts. They play an important role in immune regulation, insulin sensitivity, cardiovascular health, ovulation, and infant development. A review from 2018 concluded that omega-3 supplements may be helpful for insulin resistance in women with PCOS (Yang, Zeng, Bao, & Ge, 2018). One recent clinical study assessed omega-3 supplementation (2 grams per day) over six months, reporting decreased waist circumference and cholesterol as well as regularized periods among women with PCOS (Khani, Mardanian, & Fesharaki, 2017). Another clinical trial also assessed 2 grams per day of omega-3 supplements among women with PCOS and found that it helped with insulin metabolism, testosterone levels, hirsutism, and inflammatory markers when taken for just twelve weeks (Amini et al., 2018).
Fish Oils for Women with PCOS
The headline: Omega-3 supplementation may be beneficial for women with PCOS, especially if they are not getting enough from their diet. Find a good fish oil supplement that contains both EPA and DHA.
Several recent studies have found a connection between gut bacteria and PCOS. A study from 2018 found that women with PCOS had less diverse gut bacteria than women without PCOS, and further, higher testosterone levels in the women were associated with less microbiome diversity (Torres et al., 2018). To determine whether probiotics could alter the gut microbiome and potentially improve PCOS symptoms, a meta-analysis published in 2020 found that across nine clinical studies, probiotic supplementation significantly reduced insulin resistance, BMI, and testosterone levels (Cozzolino et al., 2020). The two common probiotics included in almost all of the studies were Lactobacillus acidophilus and Lactobacillus casei and the majority of the studies had participants supplement with probiotics for twelve weeks. Thus, it seems that probiotic supplementation with the aforementioned species may be beneficial for women with PCOS.
Resveratrol is a polyphenol found in grapes and nuts that is known for its antioxidant abilities. A study published in 2016 by researchers in Poland suggested that it may be beneficial for PCOS as well. The researchers recruited thirty women who were randomized to take either 1500 milligrams of resveratrol daily or placebo for three months. The women who took resveratrol showed a statistically significant 23.1 percent reduction in testosterone after three months as well as a significant reduction in their fasting insulin levels (Banaszweska et al., 2016). This study suggests that resveratrol can reduce androgens in women with PCOS. Further studies with a larger sample size will help confirm these findings and determine whether resveratrol is an important supplement for women with PCOS to consider taking.
Soy Isoflavones and Protein
Soybeans and soy products are rich sources of isoflavones, which are (very weak) phytoestrogens, meaning that they chemically resemble human estrogen. A couple of studies have reported that eating soy isoflavones for twelve weeks was beneficial for women with PCOS (Jamilian & Asemi, 2016; Khani, Mehrabian, Khalesi, & Eshraghi, 2011). Benefits were also reported for a diet high in soy protein (Karamali, Kashanian, Alaeinasab, & Asemi, 2018). However, a preclinical study suggested that regularly eating soy-based foods may contribute to the development of PCOS, so more research on soy consumption among women with PCOS is needed before increased soy consumption is recommended (Patisaul, Mabrey, Adewale, & Sullivan, 2014). Some functional nutritionists and doctors may not recommend soy consumption; at this point, studies have shown that eating a moderate amount does not increase your risk for breast cancer.
Lifestyle Changes for PCOS
Getting plenty of sleep is crucial, and for some women, managing weight can be important as well.
Exercise is (not surprisingly) cited as a key ingredient for weight loss in women with PCOS; it can help with myriad PCOS issues, improving insulin sensitivity, cardiovascular health, mood, and sleep. Another great benefit of exercise? Better sex. A recent controlled clinical trial of women with PCOS found that thirty to fifty minutes of aerobic treadmill training three times a week for four months improved sexual satisfaction, lubrication, orgasm, and desire while reducing sex-related pain and depression (Lopes et al., 2018).
Sleep apnea and other sleep disorders are common among women with PCOS. Sleep apnea can be caused by obesity. And your risk for sleep apnea is also affected by hormones. Because women with PCOS have lower levels of progesterone, which aids in dilating upper airway muscles, their risk of sleep apnea is five to ten times higher than that of women without PCOS who are obese (Ehrmann, 2012; Popovic & White, 1998). Furthermore, sleep disturbances may increase the risk of diabetes, high blood pressure, heart attack, and stroke (Fernandez et al., 2018).
Weight loss and continuous positive airway pressure (CPAP) are effective treatments. CPAP machines have a mask that covers your nose and mouth during sleep, delivering air pressure that keeps the airways open. CPAP has been reported to improve sleep apnea as well as insulin sensitivity in women with PCOS (Tasali, Chapotot, Leproult, Whitmore, & Ehrmann, 2011). Other tips: Avoid alcohol and sedatives before bed, and don’t smoke.
Conventional Treatment Options for PCOS
The ways health care practitioners treat PCOS vary considerably. A primary care doctor might advise you to take one medication, while your ob-gyn or endocrinologist or nutritionist might recommend something totally different. The best treatment options depend on a variety of factors, including your age, symptoms, weight, and whether you want to become pregnant (now or later). How PCOS is treated will also depend on where your doctor is putting the focus—your hormones, insulin levels, weight loss, etc. Treatment can involve anything from insulin-lowering drugs to oral contraceptives to antiandrogen therapy to lifestyle changes, depending on your individual needs. We’ve rounded up the typical treatment options so you can educate yourself and decide what’s best for you with your doctor.
Hormonal Birth Control
During the menstrual cycle, the lining of our uterus begins to thicken, creating a temporary home for an egg to implant and develop until birth. But if the egg is not fertilized—meaning we’re not pregnant—the uterine lining is no longer needed and is shed (meaning you get your period). If a woman isn’t menstruating frequently, as is the case for many women with PCOS, this uterine lining starts to build up. This extra growth can sometimes cause unusual changes that could result in endometrial cancer if left untreated. Women with PCOS are often prescribed hormonal birth control pills (pills containing progestin only or combined contraceptives, which contain both estrogen and progestin) to allow them to shed their uterine lining each month. This can help with menstrual irregularities and reduce androgen levels that are related to hirsutism and acne (Luque-Ramírez, Nattero-Chávez, Ortiz Flores, & Escobar-Morreale, 2018).
The pill may not be enough on its own. In one study assessing preconception interventions for women with PCOS, lifestyle modification in combination with hormonal birth control worked better at increasing ovulation in women with PCOS compared to the pill alone (Legro et al., 2015). An additional point to consider: There is evidence that oral contraceptives may increase the risk of breast cancer, heart attack, and stroke as well as reduce key nutrients in our bodies (Gierisch et al., 2013; Kaminski, Szpotanska-Sikorska, & Wielgos, 2013; Palmery, Saraceno, Vaiarelli, & Carlomagno, 2013). Discuss these risks and benefits with a medical professional.
Metformin and Other Insulin-Sensitizing Drugs
If you’ve tried to pull the diet and exercise levers but nothing’s going according to plan, your doctor may recommend an insulin-sensitizing drug such as metformin. While not recommended as a first-line treatment, metformin is often prescribed for stubborn weight loss in women with PCOS who also have type 2 diabetes or insulin resistance. Metformin may also be prescribed for women who cannot (or don’t want to) take hormonal contraceptives (Legro et al., 2013). The drug has been shown to help with weight loss as well as menstrual regularity (Morin-Papunen, 1998). It can be prescribed alone or with other medications such as clomiphene citrate to help with fertility (see fertility section).
The best results have been shown when metformin is taken in combination with lifestyle modifications, like a healthy diet and exercise.
Also note: There is some more recent research that raises concerns about the safety of metformin when taken throughout pregnancy and its potential lasting effects on children (Faure et al., 2018; Haas & Bentov, 2017). Discuss these risks with your doctor.
Several clinical trials studying metformin for PCOS treatment are currently underway or enrolling now; if you’re interested, see our clinical trials section for more information.
Future Treatment Options
While metformin still seems to be the gold standard insulin-sensitizing drug for PCOS, other drugs are being researched that have shown similar effectiveness, so there is hope for more treatment options in the near future. One such drug called pioglitazone was shown in a meta-analysis of eleven studies to perform better than metformin at improving menstrual regularity and ovulation, but metformin outperformed pioglitazone in terms of BMI and hirsutism (Xu, Wu, & Huang, 2017).
Spironolactone is a diuretic known for treating high blood pressure and heart failure, and it also is used long-term in women with PCOS to lower androgen levels, which are responsible for hirsutism, hair loss, and acne. In combination with oral contraceptives, spironolactone was shown in one study to work better than metformin alone at reducing hirsutism and testosterone levels (Alpañés, Álvarez-Blasco, Fernández-Durán, Luque-Ramírez, & Escobar-Morreale, 2017). Another antiandrogenic drug called flutamide is currently being studied in women with PCOS. UCLA is recruiting subjects for a phase 2 clinical trial of the drug. (For more on clinical trials and PCOS, see the clinical trials section.)
Alternate Treatment Options for PCOS
Working with a holistic practitioner who can recommend tailored herbal formulas can be helpful in managing the multiple symptoms of PCOS and supporting hormone and insulin levels. Inositol may also be useful for some women.
Inositol, sometimes referred to as vitamin B8, is a type of sugar that is found in fruits, beans, grains, and nuts. It is an insulin-sensitizing compound that has been shown to improve metabolic, hormonal, and reproductive aspects of PCOS, and there is evidence that it may be able to prevent gestational diabetes (D’anna et al., 2015; Gateva, Unfer, & Kamenov, 2018; Unfer, Carlomagno, Dante, & Facchinetti, 2012). It may also improve the effectiveness of assisted reproductive technology (ART) in women with PCOS (Garg & Tal, 2016). A meta-analysis combining ten clinical trials reported that inositol could increase ovulation and frequency of menstruation (Pundir et al., 2018). The isomer myo-inositol was found to perform similarly to metformin in treatment of PCOS (Fruzzetti, Perini, Russo, Bucci, & Gadducci, 2017). Myo-inositol and d-chiro-inositol (in a ratio of 40:1) can be found in supplement form under the brand name Ovasitol for the management of PCOS symptoms.
Holistic approaches often require dedication, guidance, and working closely with an experienced practitioner. There are several certifications that designate an herbalist. The American Herbalists Guild provides a listing of registered herbalists, whose certification is designated RH (AHG). Traditional Chinese medicine degrees may include LAc (licensed acupuncturist), OMD (doctor of Oriental medicine), or DipCH (NCCA) (diplomate of Chinese herbology from the National Commission for the Certification of Acupuncturists). Traditional Ayurvedic medicine from India is accredited in the US by the American Association of Ayurvedic Professionals of North America (AAPNA) and the National Ayurvedic Medical Association (NAMA). There are also functional, holistic-minded practitioners (MDs, DOs, NDs, and DCs) who may use herbal protocols.
The drug metformin—one of the most widely prescribed drugs for PCOS and diabetes—can actually be traced back to herbal medicine and the discovery of the flower Galega officinalis (French lilac), whose natural compounds help lower blood sugar (Bailey & Day, 2004). And there are numerous other plants that may help with common PCOS complaints, supporting healthy insulin and hormone levels.
Best Herbs for Women with PCOS?
An herbal medicine and lifestyle modification program in Australia showed the benefits of combined natural therapy using cinnamon, licorice, St. John’s wort, peony, and bindii in the treatment of overweight women with PCOS. At the end of three months, the women had more-regular periods along with improved BMI, insulin, blood pressure, quality of life, depression scores, and pregnancy rates (Arentz et al., 2017). Some herbs to look out for include berberine, cinnamon, licorice, and mint.
Herbs for Insulin Support
The compound berberine, found in various plants including barberry and tree turmeric, is often used as a supplement for high blood sugar and high cholesterol. A study of ninety-eight Chinese women with PCOS found that treatment with 0.4 grams of berberine three times a day for four months improved ovulation, insulin resistance, and menstrual pattern, especially among overweight women (L. Li et al., 2015). However, a recent meta-analysis found that while berberine has shown promise for insulin-resistant women with PCOS in a few small studies, there isn’t enough data to make any definitive conclusions about its effectiveness and more large-scale studies are needed (M.-F. Li, Zhou, & Li, 2018).
Components of cinnamon have been reported in some but not all studies to alleviate symptoms of metabolic syndrome and type 2 diabetes—all very relevant for women with PCOS (Qin, Panickar, & Anderson, 2010). Several studies have shown that cinnamon can improve insulin sensitivity. A clinical study of women with PCOS taking progestin medication found that supplementation with 1.5 grams of cinnamon per day for three months significantly reduced insulin resistance (Hajimonfarednejad et al., 2018). Another clinical study found that the same dose of cinnamon for six months improved menstrual regularity among women with PCOS, though it did not improve insulin sensitivity (Kort & Lobo, 2014). Overall, cinnamon may be useful for some insulin-resistant women with PCOS, so sprinkle some generously into your oatmeal in the morning or take a quality cinnamon supplement.
Herbs for Hormonal Support
Licorice is a common sweetener that has long been used in Chinese medicine for metabolic and reproductive disorders. Often used in combination with spironolactone, 3.5 grams of licorice can reduce diuretic side effects (Armanini et al., 2007). Glycyrrhetinic acid, the active ingredient in licorice, has been shown to improve hormonal levels and irregular ovarian follicles in animal studies. And it’s been shown to reduce testosterone in a small clinical study of healthy women (Armanini et al., 2004; H. Yang, Kim, Pyun, & Lee, 2018). If you do use licorice with the guidance of your health care practitioner, be careful about overconsumption of glycyrrhetinic acid, as several serious side effects have been reported, including hypertension, low potassium levels, and weakness in the arms and legs (Omar et al., 2012).
Several types of mints have been used to address symptoms of PCOS. Wild mint syrup has been shown in one clinical trial to induce and maintain regular menstrual periods (Mokaberinejad et al., 2012). Drinking spearmint tea twice a day for a month was shown to lower testosterone levels in women with PCOS (Grant, 2010). In an animal model, spearmint oil was shown to reduce testosterone levels and follicular issues (Sadeghi Ataabadi, Alaee, Bagheri, & Bahmanpoor, 2017). Overall, mint teas could be helpful, but more research is needed.
New and Promising Research on PCOS
The latest research is aimed at trying to better understand how specific hormones influence PCOS as well as how things like insulin and endocrine disruptors can impact the delicate hormonal balance.
A French study released earlier this year may have pinpointed a cause of PCOS—anti-Müllerian hormone (AMH), which is responsible for follicle development and sex steroid production in the ovaries. Researchers found that pregnant women with PCOS had higher levels of AMH than normal. To determine whether this could be a possible cause of PCOS, the researchers conducted another study in which they injected pregnant mice with AMH. They found that this excess AMH during pregnancy caused masculinization in utero, resulting in offspring with symptoms consistent with PCOS. They also found that treatment with gonadotropin-releasing hormone (GnRH) reversed the PCOS-like traits (Tata et al., 2018). These studies provide novel insight into the cause of PCOS and interventions to treat it. Furthermore, some researchers have proposed using AMH as a marker for PCOS, which could help with the current diagnostic problems, enabling doctors to better identify and treat PCOS (Shi et al., 2018).
What exactly causes excess AMH and male hormones? Researchers are not quite sure, but the leading theory has to do with insulin resistance. A recent study found that AMH and insulin levels were higher in women with PCOS—and that when PCOS cells were treated with insulin, the AMH levels were even higher (Liu et al., 2018). It seems that insulin resistance may contribute to the development of PCOS by increasing AMH levels. However, many women with insulin resistance do not develop PCOS, so genetic susceptibility is at play here, too. This research emphasizes how valuable it is for women (and young girls) to be able to manage their insulin levels and weight to decrease their risk of PCOS, especially if their mother has it, too (Prapas et al., 2009).
You’ve probably heard about BPA and the myriad effects it has on our reproductive and metabolic health. And you might also have heard that a recent meta-analysis found that high BPA levels are associated with PCOS (Hu et al., 2018). BPA is a xenoestrogen, meaning it mimics the hormone estrogen and can mess with your hormonal system, which is why it has toxic effects.
Avoiding BPA and Its Replacements
Although most products you see today are “BPA-free,” be wary of plastic in general. Companies can replace BPA with chemically similar compounds, such as BPS, that have not been adequately studied to know whether or not they are safe. In general, whether you have PCOS or not, avoid using plastic as much as possible (if not for your health, then for the environment), especially near your food. Microwave food in glass containers and ditch your plastic water bottle for a reusable glass or stainless steel water bottle.
The Adrenal-Hormone Connection
In women, testosterone is produced in multiple places in the body, including the ovaries, the adrenal gland, and various tissues. And researchers have started looking at whether women with PCOS have issues with hormonal levels in their adrenal glands as well as their ovaries. In a 2018 study, researchers in Italy studied the saliva of young girls with PCOS after they filled out a questionnaire and again after an examination with an endocrinologist, which was supposed to simulate stress. They found that the salivary cortisol levels (the stress hormone) were higher among the girls with PCOS compared to healthy controls without PCOS. Thus, their HPA axis, the stress response system, was shown to be highly overactive. The researchers also found that this overactivity in the HPA axis was related to worse metabolic health than that of the controls (Mezzullo et al., 2018). This study points to how controlling our stress response can have a direct impact on our metabolic function and overall health.
Clinical Trials on PCOS
Clinical trials are research studies intended to evaluate a medical, surgical, or behavioral intervention. They are done so that researchers can study a particular treatment that may not have a lot of data on its safety or effectiveness yet. If you’re considering signing up for a clinical trial, it’s important to note that if you’re placed in the placebo group, you won’t get access to the treatment being studied. It’s also good to understand the phases of clinical trials: Phase 1 is the first time most drugs will be used in humans, so it’s about finding a safe dose. If the drug makes it through the initial trial, it can be used in a larger, phase 2 trial to see whether it works well. Then it may be compared to a known effective treatment in a phase 3 trial. If the drug is approved by the FDA, it will go on to a phase 4 trial. Phase 3 and phase 4 trials are the most likely to involve the most effective and safest up-and-coming treatments.
In general, clinical trials may yield valuable information, may provide benefits for some subjects, and may have undesirable outcomes for others. Speak with your doctor about any clinical trial you are considering. To find studies that are currently recruiting for PCOS, go to ClinicalTrials.gov. We’ve also outlined some below.
Heather Huddleston, MD, at the University of California San Francisco is currently recruiting women to study whether paleo diets (compared to the American Diabetes Association diet) are effective for people with PCOS. Previous research has shown that paleo diets are useful for type 2 diabetics and people with insulin resistance, so the hope is that the same will be the case for PCOS.
Eleni Greenwood, MD, at the University of California San Francisco is currently recruiting women with PCOS for a phase 4 clinical trial to determine whether metformin or vitamin D is more effective for treating depression. A phase 4 clinical trial is intended to verify the long-term effectiveness of new treatments.
Dance for Adolescent Girls
Since adolescent girls are less likely to exercise than their male peers, Christine Solorzano, MD, and researchers at the University of Virginia are partnering with the National Institute of Child Health and Human Development to create a dance-based program for adolescents with PCOS, abnormal weight gain, insulin resistance, and diabetes. The study is currently recruiting and is open to girls ages ten to eighteen.
Karen Elkind-Hirsch, PhD, and researchers at Woman’s Hospital in Baton Rouge, Louisiana, are studying liraglutide, an antidiabetic drug, to see whether it improves body weight, hormones, and cardiovascular outcomes in obese nondiabetic women with PCOS. The study will last thirty weeks, and liraglutide will be taken in combination with diet and lifestyle coaching. This is a phase 3 clinical trial, meaning that the drug has already been tested for safety, dosage, and side effects in several hundred people before this stage. For more information on other antidiabetic drugs used in the treatment of PCOS, see the conventional treatments section.
Astronauts and Vision Issues
You may not know that when astronauts return from their heroic trips to space, they often come back with issues such as loss of bone density or eye issues. And NASA is recruiting for a clinical trial to study whether there is a genetic connection between women with PCOS and the vision issues that astronauts encounter on long-duration spaceflights, which may lead to long-term cardiovascular issues. The study is recruiting nationwide; the researchers hope to shed light on the one-carbon metabolism pathway and how that may affect the vision of women with PCOS and the vision of certain genetically susceptible astronauts post–space travel.
• The Centers for Disease Control and Prevention (CDC) provides evidence-based information on PCOS and diabetes risk.
• Johns Hopkins Medicine provides clinical information on PCOS diagnosis and treatment.
• The National Institutes of Health (NIH) offers information about PCOS symptoms, causes, diagnosis, treatment, and research.
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