PCOS Nutritionist in London

Polycystic Ovarian Syndrome (or PCOS) is a complex hormonal condition of too many androgens that negatively impact ovulation.

Androgens are made in the ovaries AND, very importantly, in the adrenal glands (as well as some fat tissue). They are typically considered the “male” hormones but, as women, we absolutely need them too for focus, energy, a fired up sex drive and building muscle. As with anything in life, androgens become an issue when they’re in excess, which is what happens in PCOS and, amongst other things, they then negatively impact ovulation.

Ovulation is the process where an egg is released each cycle. Every month, there will be 6 – 12 developing eggs, or follicles. If ovulation occurs, one becomes dominant & is released and the others are reabsorbed. In the case of PCOS, there isn’t a dominant follicle to suppress the growth of the other follicles so we end up with many small undeveloped follicles growing just a little bit and that’s what is seen on ultrasound (often referred to as the PCOS ‘string of pearls’).

Here’s the thing though: ovulation is about SO MUCH MORE than just making a baby. Not only is it part of our Essence as women but it’s also considered the six ‘vital sign’ because it is that much of an important indicator for our health. We need regular ovulation to make hormones, for our skin health, our heart health, our bone health, our brain health, our metabolism. In other words, ovulation is a properly big deal!

There are other reasons beyond PCOS that can impair ovulation but in the case of PCOS, those high androgens are where our attention is at.

This is the question I’ll be asking myself with each and every client I see – because I take a functional medicine approach, I will push as far upstream as possible to piece together your unique story to understand why androgens are high in your individual case. (As a side note, it’s important to be aware that there can be other reasons beyond PCOS for high androgens.)

But before we get into that, there is something very important that we need to discuss.

Firstly, although research has shown that there very much so is a genetic component to PCOS and high androgens, something that has to be stressed with all the big, bright, flashing neon lights is that genes can be turned on and off by the environment they’re in.

This is called epigenetics.

Let’s use a simple analogy of two apple trees. One apple tree is in one field and producing the sweetest apples you ever did taste while the second apple tree is in another field, with zero sign of fruit and just overall, doesn’t look great. When the farmer comes along, she doesn’t look at the tree with no fruit and blame the tree itself, she’ll look at the environment that it’s in: the soil, the water, the sun, the wind. She asks whether there are pests present? A fungus maybe? Perhaps extra nutrients need to be added? So she looks at the environment that the tree is in and makes changes there.

And this is so true when it comes to PCOS: the syndrome will develop in a given environment *BUT* through tweaking that environment, PCOS symptoms can be reversed.

And we know that high androgens are a big part of the PCOS picture so what are two of the main drivers in the environment that are behind high androgens?

Inflammation and/or Insulin resistance.

We’ll go into a bit more detail about these now but we often need to zoom out even further and see what else within the environment is causing the inflammation and/or insulin resistance. So, inflammation and/or insulin resistance are the drivers to the high androgens but what’s the fuel that keep them going?

This is essentially where we get to finding the root cause.

These can range from really simple things to more complex things.

The root cause(s) allowing the inflammation and/or insulin resistance of PCOS to be present in the environment and therefore trigger high androgens can be anything from digestive issues, presence of parasites or pathogens, food sensitivities, when, what and how we’re eating, a tweaking out thyroid, lack of sleep, stress, strained relationships, a muddled mindset, exercise that’s not suited to your body, environmental toxins, childhood trauma, mould exposure and more.

It’s important to note that there often isn’t just one ‘root cause’ but rather a combination of the above and THIS is why taking a functional approach is so essential, rather than trying to find a silver bullet solution.

In the short term, we’re all about inflammation: it’s our body’s natural way of protecting itself through activating the immune system. You’ve experienced it as the redness, heat and tenderness after stubbing your toe or getting a paper cut.

But chronically, it’s not our favourite because it interferes with hormonal communication throughout the body. When it comes to PCOS, research suggests that it is an inflammatory condition.

Inflammation can cause the ovaries and the adrenal glands to make more androgens and that’s what we experience as hairy chins and chest and bellies, or angry jawline acne, or male patterned baldness or no ovulation. Other tell-tale signs of chronic inflammation in the body include painful joints, eczema, allergies and fatigue.

Not all women with PCOS have insulin resistance but studies show that approximately 70% do. (It’s also important to note that not all women with insulin resistance develop PCOS.)

Insulin is a hormone that helps the cells in our body bring in something called glucose, which they then use to make energy. Insulin resistance is when this process happens less efficiently (and can be because of a number of reasons). As a result, we end up with a whole heap of excess insulin.

But more insulin is a problem when it comes to those androgens, and here’s why.

Firstly, high levels of insulin stimulate the ovaries to make testosterone instead of estradiol (through causing theca cells to enlarge).

Secondly, high levels of insulin also cause a drop in sex hormone binding globulin (SHBG) production. SHBG is like a little bus that transports the hormones around the body to where they need to be going, ensuring that they don’t run rampant. So, when SHBG is low (owing to the high insulin), it’s like the London buses are on strike but there are the same number of people to transport about and we all know how chaotic that can get. The same is true when SHBG is low: low SHBG but the same number of hormones to transport around the body, means that there’s more free hormones (particularly testosterone) floating about the place. We then experience this as the typical PCOS symptoms.

For a very long time, it was thought that one had to be of a fuller weight in order to have PCOS. This however is not true as approximately 30% of women with PCOS do not experience weight gain; weight gain is just one symptom in PCOS and won’t express for everybody. It’s also important to note that insulin resistance can still be at play even when weight gain isn’t part of the picture.

On this note, when weight gain isn’t a concern but you’re struggling with ovulation? I would then suggest speaking with your trusted medical doctor to investigate other conditions such as Hypothalamic Amenorrhea or Congenital Adrenal Hyperplasia which can present similarly to PCOS.

I’m not a doctor and I cannot diagnose any condition but that’s not what I’m interested in anyway. My focus is always to understand your individual body through a functional lens – one that keeps asking “What’s going on in there for you?”, one that views your body as a unique & beautiful tapestry of interconnected systems, one that knows that symptoms don’t just arise for no reason even if “test results are normal”.

But when it comes to PCOS, I want to make a couple of things really clear.

Firstly, you cannot be diagnosed with PCOS by ultrasound alone and neither can the absence of ‘cysts’ on the ovaries be used to rule out PCOS. Here’s why:

The Rotterdam Criteria is what it is traditionally used when diagnosing PCOS and it states only two of ANY of the following three criteria need to be met for diagnosis:
1. Infrequent or no ovulation
2. Raised androgens seen as either physical signs + symptoms (such as excess hair growth, acne + hair loss) and/or through blood tests
3. Polycystic ovaries as seen on ultrasound

So if we only need to meet two of any of the three criteria, then as you can see that means you can have infrequent or no ovulation with raised androgens and NO polycystic ovaries in order to meet diagnosis.

But the Androgen Excess Society took this a step further in 2009 by releasing a report that emphasises that PCOS does need to be defined by the presence of raised androgens.

Secondly, PCOS is one of the most ridiculous names in the whole world and it contributes HUGELY to the confusion.

This is because they are not cysts – they’re follicles that were never released when ovulation should’ve occurred; they’ve essentially become ‘stuck’. Every month, there will be 6 – 12 developing follicles. If ovulation occurs, one becomes dominant & is released and the others are reabsorbed. In the case of PCOS, there isn’t a dominant follicle to suppress the growth of the other follicles so we end up with many small undeveloped follicles growing just a little bit and that’s what might be seen on ultrasound. It’s also been shown that women without PCOS can have ‘cysts’ on their ovaries as seen on ultrasound. And, to add to all of this, by taking the Androgen Excess Society’s stance on how androgens DO need to form part of the PCOS picture, we know that androgens are made in the adrenal glands (plus some fat tissue), and not just the ovaries. But even then, we will always still take a full body approach, not just laser-focus on your ovaries or adrenals.

Finally, we also need to bear in mind that PCOS is a diagnosis of exclusion. This means that other conditions need to be ruled out before arriving at a PCOS diagnosis. As mentioned above, other conditions such as Hypothalamic Amenorrhea and Congenital Adrenal Hyperplasia (amongst others) can present similarly to PCOS. It’s also important to note that there cane overlap with other conditions and PCOS. But even then, we’ll still keep coming back to you, your body, your story and how and why you’re experiencing the symptoms that you are.

Although clinical signs and symptoms can provide many clues in piecing together your individual story, certain tests can be extremely helpful too in guiding nutrition and lifestyle interventions.

Some of the standard blood tests that I will run with my one-to-one clients include: fasting insulin, fasting glucose, HbA1C, testosterone, DHEA-S, a free androgen index, sex hormone binding globulin, luteinizing hormone, follicular stimulating hormone, prolactin, a full thyroid panel (including antibodies), vitamin D levels, CRP. These are then interpreted together with your individual signs, symptoms and timeline.

If there are other signs and symptoms at play (such as digestive symptoms) that don’t shift through the implementation of certain foundational nutrition and lifestyle factors, then additional testing in these areas might be indicated. If this is the case, the need for additional testing will always be explained to you so that you feel confident in knowing what and why we’re testing.

Even though testing can be really useful, there is not one test that can diagnose PCOS. (And again, I cannot diagnose PCOS.)

Conventional approaches for PCOS tend to suppress symptoms without actually considering what might be causing them in the first place.

One of the main options given to women for PCOS is the birth control pill in order to ‘regulate’ cycles. One of the biggest concerns I have with the pill when it comes to PCOS is that it actually suppresses ovulation and ovulation is exactly what we’re trying to restore in PCOS so how is stopping it a solution? The pill has also been shown to worsen insulin resistance which, as we know, is one of the main drivers behind raised androgens and therefore impaired ovulation. The pill has also been shown to strip the body of beneficial nutrients (such as B vitamins and zinc) which are essential for ovulation. And while the pill does help to suppress androgen production, it only does so for the duration of taking it and then once it’s discontinued, we usually find a surge in androgens which can initially make matters check of a lot worse.

Metformin and Spironolactone are two other drugs typically used for addressing insulin resistance and indirectly blocking the effects of raised androgens, respectively. In the instance of Metformin, a study indicated that lifestyle and nutrition modifications were in fact more beneficial in managing PCOS than Metformin and/or Clomid.

While I fully appreciate that there is a time and place for medications, at the end of the day, you know yourself and your needs best so you have to make the decision regarding the use of any of these for yourself – all I ask is that this decision comes from an informed place and one that sits best for you in whatever your life is right now.