When we hear that a woman is having trouble getting pregnant, our thoughts usually run to what we think of as the usual culprits, including: advanced age, fibroids, endometriosis or blocked fallopian tubes. But the reality is that most cases of infertility are caused by problems with ovulation. If a woman doesn't ovulate, there's no egg to be fertilized, and the most common cause of ovulatory problems is a little talked about -- and frequently undiagnosed -- health problem called polycystic ovary syndrome, or PCOS.
What Is PCOS?
PCOS is an inherited condition and is the most common hormonal disorder of women of reproductive age, affecting 5-10 percent of all women. PCOS can cause infertility by interfering with the exquisite hormonal balance needed for eggs to mature on schedule and be ready to be fertilized. Equally concerning, 60 to 70 percent of women with PCOS are obese, and are at significantly higher risk of developing diabetes (without treatment, about 50 percent of women with PCOS will be diabetic or pre-diabetic by the age of 40), heart disease and endometrial cancer.
The hallmark sign of PCOS is lack of regular menstruation, but there are also a cluster of telltale signs and symptoms that may suggest the diagnosis:
- Blood tests suggesting hormonal imbalances
- Excess hair growth on the face, back, chest or abdomen
- Thinning hair on the crown of the head
- A tendency to accrue that much-maligned belly fat around the middle.
As you can imagine, for many women PCOS can also set the stage for a major crisis of body image and female identity.
What Causes PCOS?
The connection between PCOS and fertility has been recognized for over 100 years, but only since the 1990s have scientists begun to appreciate that "ground zero" for PCOS in most women is insulin resistance, the same hormonal problem that, in its most advanced state, causes type 2 diabetes. This finding gives us great insight into how to treat women with PCOS beyond the historic "Band-aid" approach of treating the symptoms -- birth control pills to regulate a woman's period; laser treatment or medications for hair growth; a trip to the dermatologist to manage acne; and, of course, a non-stop onslaught of recommendations to lose weight.
Like reproductive hormones, insulin is a hormone with far-reaching action. Insulin is produced by the pancreas, and its main job is to escort glucose, or blood sugar out of the blood and into the cells after we eat carbohydrates (both sweets or added sugars, and naturally occurring carbs, like grains, starchy vegetables, fruits, milk and yogurt). The amount of carbohydrate eaten dictates how much insulin is secreted to clear glucose out of the blood. In insulin resistance, the pancreas releases insulin into the blood, but the cells resist its cell-opening action, causing the pancreas to compensate by working overtime to pump out excess amounts. Over time this can lead to pancreatic "burnout" where not enough insulin is being produced to overcome the resistance, leading to a gradual rise in blood glucose levels -- and an increased risk of diabetes.
From a reproductive standpoint, excess circulating insulin also has the ability to stimulate production of the male-type hormone testosterone in the ovaries, a place where estrogen needs to dominate to trigger ovulation. It's these male hormones that can cause unsightly growth of facial hair; wreak havoc on hair follicles on the crown of the head (leading to male-pattern hair loss); stimulate inflammation and acne in the skin; and direct fat deposits to the abdomen in a male-type distribution.
Not All The News Is Bad. PCOS Is Very Treatable
Because PCOS is genetic, there is no cure, but it is treatable. Metformin, a diabetes medication that improves insulin sensitivity, is often used, particularly in women trying to conceive. Birth control pills and other medications may also be prescribed to help manage symptoms, but, like many modern-day health problems, diet and lifestyle change is key. Being overweight and sedentary aggravates insulin resistance, worsening the symptoms of PCOS and raising the risk of infertility and other health complications. Adopting a few healthful diet and exercise strategies that target insulin resistance -- including weight loss, if necessary -- is critical to managing the underlying hormonal problems seen in PCOS, and truly experience relief from its symptoms:
- As carbohydrate intake dictates the post-meal glucose/insulin response, limit sweets in favor of moderate-sized portions of unrefined carbohydrates, like whole grains, fruits, starchy vegetables, low fat milk and unsweetened yogurt -- spread out over smaller meals and snacks.
- Pair carbohydrates with lean protein and a little healthy fat (for example, whole grain crackers with peanut butter, or stir-fried chicken and vegetables with brown rice) to help slow carbohydrate digestion and enhance the feeling of fullness you get from meals and snacks.
- Trade in trans and saturated fats for heart-healthy monounsaturated fats from olive, canola or peanut oil, nuts, seeds and avocados, and increase your intake of anti-inflammatory omega-3 fats from fatty fish (salmon, mackerel, herring, lake trout, sardines and albacore tuna) or fish oil capsules if you're not a fish eater.
- Take exercise seriously. It's the most natural insulin sensitizer there is. Aim for at least 30 minutes most days with a long term goal of 60 minutes (can be accrued over the day).
Infertility is a major concern for many women with PCOS, but under the care of an OB-GYN or reproductive endocrinologist skilled in managing PCOS, many women are able to conceive. A registered dietitian can also be a great help in making the changes needed to manage PCOS as naturally as possible. For over 10 years I've been helping women with PCOS understand their condition, become empowered to manage their health, and, in many instances, have the babies they once thought they couldn't. You can find a registered dietitian in your area through the American Dietetic Association.