S1 E11: PCOS Part 1


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Amanda: Hey, this is Amanda, women’s health dietitian.
Emily: And I’m Emily, nutritional therapy practitioner.
Amanda: And this is the Are You Menstrual? podcast where we help you navigate the confusing world of women’s hormones and teach you how to have healthy periods.
Emily: Each week we will be diving into a different topic on women’s health and sharing our perspective using nutrition, female physiology, and metabolic health.
Amanda: Our goal is to help you wade through conflicting health information and empower you on your healing journey.
Emily: We hope you enjoy it.

Emily: Today we are going to be covering a women’s health topic that is actually very near and dear to my heart. And it’s what got me involved in the wellness space to begin with. And that’s PCOS or polycystic ovarian syndrome. So you might or may not know that PCOS is actually the leading cause of infertility in the United States. And it’s a problem that affects 1 in 10 women of childbearing age. So that’s a lot of women. And the worst thing about this is that there’s still so much confusion surrounding this modern syndrome and what actually causes it…even down to its name, which we’ll talk about it, is a complete misnomer making it even more confusing. But we’ll get into that in the episode. Amanda and I have both dealt with the symptoms of PCOS at different points in our lives. Again, something we’re going to talk about. And we know that so many women struggle with it, which is why we wanted to devote two whole episodes to this particular hormonal health challenge. And let’s just be honest for a second—there is a ton to unpack here. There’s so much that goes into PCOS, like what drives it, the symptoms of it, what can be done about it, and we’re gonna try to do our best to clear the fog surrounding this condition and just make it a lot less confusing than maybe it is to you. So we hope this episode is helpful for any of you who may have the symptoms of PCOS, or may have been diagnosed recently, or think you should be diagnosed…whatever it is that you’re going through related to this condition. We hope that this is helpful.

Amanda: And so the first area that we’re going to get started with is how is PCOS is diagnosed. And there’s actually three criteria that were created by leading experts in 2003. And it’s, it’s typically known as the Rotterdam criteria. You only have to have two out of the three to be diagnosed, and I think this is where a lot of the confusion comes in when you go to the doctor. Ideally, most doctors are following this criteria—not all of them do. But the three kind of areas where you need two out of the three are the following:

One is delayed ovulation or menstrual cycles. So anovulation, or not having an ovulatory cycle, is defined as fewer than 10 menstrual cycles per year or cycles that are longer than 35 days. So the way that you’d have to fit into this category is if your cycles are longer than 35 days or if you have less than 10 cycles per year. Most women are likely tracking their cycles so that, I think the cycle length is the easiest and least confusing way to go about that.

The next one is high androgens. Now this could be symptoms or it could be lab tests. So you can have high androgens on your lab work like testosterone, DHEA, DHT and some of the androgen metabolites. Or you could have the presence of high androgen symptoms. So these are things like acne…hair growth is probably the most common one that we see where you could have hair growth on the chin, upper lip, chest, belly, nipples…Or hair loss, so male pattern baldness is another really big one. So if whether you have the high labs on your bloodwork or your Dutch test, or the symptoms, or both, that would count as having high androgens.

And then the last kind of part of the criteria is polycystic ovaries. Now, oftentimes people assume that you have to have cysts on your ovaries to have PCOS, but you could have longer cycles, like have the irregular cycles, and the high androgen symptoms and that would give you two out of the three—so you don’t have to have cysts on your ovaries to get diagnosed with PCOS. If that is one of your criteria…say maybe you don’t have high androgens but you have irregular cycles and you do have some cysts. Technically it’s supposed to be 12 or more follicles that are going to be measuring from two to nine millimeters or an ovarian volume larger than 10 centimeters in one ovary.

So those are the three criteria, you need two out of the three to be diagnosed. I was personally diagnosed with post-pill PCOS after I came off the pill and I didn’t have a period for almost a year. So I did have cysts on my ovaries because I wasn’t ovulating, right? So it’s very common. You’re gonna…those follicles aren’t fully developing so they’ll be turned into cysts. And then I also, obviously I didn’t have the cycles—I wasn’t ovulating or having any cycles. So that was like the second criteria. And I actually did have high androgens. So I met all three out of three. But I will say that I did have hypothyroidism at the time too. So thyroid issues can look very similar to PCOS, which is why you want to rule out thyroid as being the root cause of these symptoms. Often PCOS and thyroid go hand-in-hand, which we’ll talk about. But I had three out of the three—not everyone does. They can resolve, right, because I had post-pill PCOS. So once I started ovulating again, all of those things eventually went away. And if I went to the doctor today, I would not be diagnosed with PCOS.

Emily: My story is a little bit different than Amanda’s. I had not been on the pill for a really long time. So when I was experiencing all these PCOS symptoms, like the hair growth in unwanted places, the acne, the irregular periods, I went to my OB…I think this was in 2012 so I was in college…and what’s interesting is that even though I, she tested my blood and I had slightly higher androgen levels than normal, I also had the anovulatory cycles. So that’s, that’s two out of the three right there. She wanted to do a vaginal ultrasound, and she did not find any cysts on my ovaries. So she told me that I did not have PCOS and that, she put me on spironolactone for the mildly high androgens and called it a day. Just a spoiler…the spironolactone did not work. So I ended up going back to the doctor about two years later with the same exact symptoms. And that’s when my NaProTECHNOLOGY doctor told me you definitely are on the spectrum of PCOS—you have two of the three criteria. And I was also diagnosed with hypothyroidism, which surprise surprise, these two often go hand-in-hand as Amanda mentioned. 

So this is why I mentioned at the beginning of the episode that polycystic ovarian syndrome, that name is actually not entirely accurate. It definitely is a misnomer. And the reason is, is because you do not have to have polycystic ovaries in order to be diagnosed with PCOS. So that name can be really confusing for a lot of people. And unfortunately, back in you know, 10 years ago in 2012. Not all of these OBs and doctors were using the Rotterdam criteria. So even though I had two of those three criteria, I was still basically ruled out for PCOS because I didn’t have cysts on my ovaries. So if you’re someone that like me has gone to an OB and been told that you don’t have PCOS just because you don’t have cysts, it may be more worth looking into and investigating with a different doctor, because nowadays hopefully most doctors are using this criteria. And keeping in mind that, you know, the number of cysts or any cysts on your ovaries doesn’t, it’s not the end all be all of PCOS despite its name.

And interestingly, on the flip side, having cysts on your ovaries doesn’t mean you have PCOS either. So research has actually shown that healthy women have polycystic ovaries about 25% of the time. And if you think about this it makes sense, because polycystic, that word literally means multiple follicles. So a healthy woman who grows new follicles every month, that’s normal, and then one becomes dominant, which leads to ovulation, right. So as Amanda said, if you, if you do have multiple follicles, it could be normal for you. It also could be a sign that maybe you’re not ovulating every month, it kind of really just depends. And you have to dig deeper with your doctor to figure out what’s going on there. But 25% of the time this is not anything abnormal. And it’s with elevated androgen levels, like in PCOS, that these follicles don’t develop properly and ovulation doesn’t always occur. So that is going to be more leading to those hormonal imbalances and those unwanted symptoms of PCOS.

Amanda: And that’s really how post-pill PCOS comes about. Because typically, when you come off the pill, you—especially if you’re on a progestin-only pill, which I was—when you come off that pill you…it acts much more like androgens progestin. It’s not like progesterone in the body and then you have this rebound of higher androgen. So that leads to like, more oily skin, you can get hair loss, more acne, all that kind of stuff. And that’s what can also delay you from ovulating again, and plus you have to remember if you’re on the pill, your brain is not communicating with your ovaries right? You’re not getting that signal so it can take time for that to come back, and I think that’s totally normal. But because I had these higher androgens and no cycle, that’s kind of how you can typically be diagnosed post-pill. If you didn’t have any of those issues prior to going on the pill—which I like to say that I didn’t, but I started taking the pill when I was very young so I feel like it’s kind of hard to know—then it could just be post-pill PCOS. But that’s, that’s just kind of like one other piece of the puzzle, because I know a lot of women come off hormonal birth control, and they’re like, what the heck is going on?

But what are, what are some of the symptoms of PCOS, right? Like, we kind of mentioned some of the hair growth ones, that sort of thing. But I would say like, if we were going to come up with a list of the most common symptoms that we see, as a result of those hormone imbalances with PCOS, they would be the irregular cycles or no, having no cycle at all, difficulty getting pregnant, because of that, you’re not ovulating, right? So if you, if you’re not ovulating, you can’t release the egg and get pregnant. Excessive hair growth, usually on your face, chest, back, or buttocks. You can also, I see it a lot below the belly button in women. Hair loss is a very, very common one or hair thinning. And then weight gain or the inability to lose weight, because most women with PCOS are on some spectrum or have some spectrum of insulin resistance, which we’re going to talk about. And then oily skin or acne, usually it’s both. Constipation, fatigue, mood changes, anxiety, or depression.

I think the mental health aspect of PCOS is not talked about a lot. And because your hormones are out of balance, you don’t have that progesterone, that feel-good hormone, it…you can deal with more anxiety and depression. I think that’s a huge part of it. And then for those women that are cycling, whether it’s, maybe some women have completely normal cycles and have PCOS, they tend to have a lot more PMS. I will say period pain is not a symptom of PCOS. A lot of people say that—it’s not a symptom of PCOS, it’s not connected. I mean, you could have low progesterone, which if you listen to the last episode, we talked about congestive period pain that’s often a result of low progesterone. But PCOS does not directly cause period pain. 

Emily: And I think it’s worth mentioning too that, and I think you actually did, these PCOS symptoms can be really mild, they can be really severe. I’m pretty sure that looking like through this list, I’ve experienced every single one of these either at the same time or at different times. But you definitely, it’s not always clear cut, right. So you really need to be in tune with your body and kind of know what’s normal for you sometimes in order to suspect PCOS. And as Amanda said, the mood changes, the anxiety, and the depression…it’s not really talked about. But speaking from personal experience, there was so many years where I did not know what was wrong with me because of these mood changes that I would go through all the time. And now looking back, I know that it was a combination of that PCOS and hypothyroidism that was leading to these. So it’s always good to know what could be behind your PCOS and what symptoms are related to that.

But we are going to talk a little bit now about the drivers of PCOS. And this is kind of where it gets into the more hairy or confusing part, because there are a lot of drivers of PCOS. But we’re going to talk about three really big ones, the ones that we find in so many of our clients, so many women that we’ve talked to and worked with, that when you go back to the basics, like, these are going to be the three things that are really at the root of what’s going on with PCOS. And I’ll just go ahead and say that most people, they think about PCOS and they automatically go to insulin resistance. Like, that’s been told that if you have PCOS you have insulin resistance, and a lot of women do have a, at least some degree of insulin resistance even if it’s small, that will contribute to your symptoms. But that’s not the only thing. There’s also two others, which if I just named the three outright, it’s going to be inflammation, specifically in the gut. Another one is insulin resistance. And then the last one is your stress and adrenals. So Amanda is going to talk a little bit about the stress component, but just to give a little bit more information on the inflammation and insulin resistance… So these two things, and all three actually, are going to kind of affect one another. So you could have all three and chances are if you have one, you probably do have more than one because of how the body works. So nothing is an isolation, right? Every system works together. So if there’s dysfunction in one system, there’s probably going to be dysfunction another.

So let’s just start with the gut. So if we’re talking about inflammation, we’re going to see impaired digestion, the symptoms that come with that, and then typically absorption of your food and nutrients is going to be low. So you’re not going to be getting all of those good nutrients no matter how well you’re eating, no matter how varied your diet is. That’s going to be problem number one, right. You’re just not digesting those things that we need to keep our hormones healthy. So then you might see an increased cortisol and estrogen levels, which kind of goes hand-in-hand with lowered progesterone. So that’s kind of those estrogen dominant symptoms that you might see, which will manifest typically as PMS, weight gain, acne, and those mood changes we talked about. Okay, so that’s just kind of the first thing, like inflammation, and that can affect, like, how your body responds to insulin.

Amanda: And I think one thing, just to kind of put in there quickly, is the reason a lot of women with PCOS have, the more, I would say, like more of a tendency to go towards inflammation and gut issues is because what the research shows us is that they have depleted beneficial bacteria. So if you’re already in a place where you don’t have as much beneficial bacteria, that’s going to completely change the environment in your gut, right. And so that will impact your digestion, absorption, inflammation. And then of course, those are going to drive, like Emily said, the cortisol and the estrogen. So it’s like, you could have digestive issues, but I think that women with PCOS in general are just like much, they have more of like a sensitive digestive system and environment because of the low beneficial bacteria.

Emily: For sure, thank you for pointing that out. And then number two, as I said, was insulin resistance. So insulin resistance is going to impair ovarian function. And that’s what increases those androgens. So your ovaries start producing more testosterone because of the impaired ovarian function. And then this will manifest as, obviously, high androgens, but that looks like irregular cycles, hair growth and loss, the male pattern baldness, the acne, the weight gain, and then the infertility. So as I said, these two, and Amanda will talk about the third, but they go hand-in-hand a lot of the time. So if you have one, you probably have the other and vice versa, which makes it confusing to know what’s actually driving your PCOS.

Amanda: I know we, we like to put things in categories, right? We want to know what type, what type is my PCOS. So what I do for this type, it’s like, it’s really hard to separate. I’m going to talk now about the stress and adrenal PCOS. And I don’t personally think that this is just a unique type, because I do think it always connects like if you have higher stress and stress hormones, you’re going to have some level of insulin resistance, right? Because that cortisol is definitely going to impact blood sugar. And then the more blood sugar impairment you have, the more insulin issues you’re going to have. And then same thing with the inflammation and digestion, right? If you’re constantly in this fight or flight state, then you’re not going to be digesting and absorbing your food well, you are going to go more towards the inflammation and estrogen dominance. And then of course, that’s going to circle back…I mean, even if we just think about how estrogen impacts insulin, right? Estrogen tends to bind to thyroid hormone. If we have excess estrogen, we make more of these proteins that will bind up thyroid hormone and impact thyroid levels, that’ll impact how we’re storing glucose in the liver. And then boom, how we keep our blood sugar balanced all day. 

So if you are someone that has like higher DHEA and higher cortisol output, that can drive your androgens and then lower your progesterone, right? Progesterone protects us from stress—it’s an anti-inflammatory hormone. And a lot of times for women with the higher stress adrenal output in PCOS as being one of their main drivers, it’s typically going to manifest as the high androgens, irregular cycles, and some level of insulin resistance. But I have seen so many women that like they, they’re like, oh, I have adrenal PCOS. They have high DHEA, but they have regular cycles, they always ovulate, but they have very low progesterone output. Like they don’t have strong ovulation. And they’re, they have blood sugar issues that take a while to get back into balance. So it can feel confusing when you’re like, which category do I fit into. But we don’t recommend putting yourself in a category. You don’t have to do that in order to improve your symptoms is kind of how we look at it. All of them are going to impact insulin resistance and your metabolism, right. So if you are tempted to do that, try not to. We are going to go more into in the next episode, like, how to address different things. But everything we’ve talked about so far on this podcast, will help you if you fall into any three of these categories. So try not to let that make you think that you don’t know what to do for your type of PCOS. Because if you’ve gone through everything you definitely do.

Emily: Yeah, and I just want to point out really quick, too. I feel like there’s even more confusion thrown into the picture when people start categorizing as like lean PCOS versus, I don’t know, non-lean PCOS or classic PCOS. And the reason is, I think a lot of people will say, they’ll put lean PCOS with the adrenal type, right? Yeah, you may if you’re lean and you have PCOS maybe it’s, it’s more your adrenals. And I fell into this trap too when I first was diagnosed and you know, when I was like, well, what type do I have? What is this coming from? What’s driving my PCOS. And so I automatically kind of grabbed on to that, oh, it must be my stress and adrenals. I’m constantly on the go go go, my cortisol is high, my DHEA is high. But realistically, if you looked at other things going on in my body, like my, my gut, and what was going on with insulin, and my hormones, you could very well see that no matter what I look like on the outside, I was experiencing all three of these. And that’s what Amanda is trying to say is that it’s really not about which category you fall into. It’s more so an understanding of, I probably have a marginal piece of all three of these drivers. And so what does that mean for how you treat it or address it? Basically, going back to the metabolism, and this is why. And if there’s one takeaway that you, you grab from this episode is that PCOS is a metabolic issue, period.

Okay. So even though things like inflammation and stress and insulin resistance and high androgens are typically seen as the causes—they are also actually symptoms. And the bigger question is what is causing the insulin resistance and the high androgens and the inflammation and the dysfunctioning adrenals. That is what we need to ask ourselves. And that is going to be the best thing we can think about when it comes to how we address our symptoms, and how we address our overall health, right? So these things are communication from your body that something is off, and they’re all impacted by our metabolism. Which if you think about it makes a lot of sense, because it’s estimated, as I said, that at least 25% of women with PCOS also have undiagnosed hypothyroidism. So what is hypothyroidism? That is a sign of a sluggish metabolism. Okay. So again, this all goes back to the metabolism, and why would we focus on anything else but the metabolism to support someone with this condition. If we just nitpick, like, okay, I need to address the stress or I need to address the insulin resistance, you’re only addressing one piece of the puzzle. If you go back and you look at the bigger picture, which is your metabolism, you’re going to be addressing all of these things at one time, because they are just the symptoms.

Amanda: And that’s where the whole spectrum comes into play. Right? Like, instead of categorizing people based on their PCOS type, we try to think more about where in the spectrum are they falling on? Like, are they leaning more towards one side, because I do think that will change like how you’re starting off on your journey, maybe what you’re focusing in on the most. And we’re going to talk about, like, testing and stuff like that that you can do. But there are so many metabolic markers that you can use to start to understand how sluggish is your metabolism. And we do see women with all types of PCOS that kind of fall into different areas of that spectrum. And that is the common denominator—is their metabolic function. And a lot of people will say PCOS is a hormonal issue. But it’s not just hormonal, though hormones, as like, we kind of recognize are more of a symptom of this deeper metabolic imbalance. And so one of the first ways that you can start looking at, how are your metabolic markers so that you can see as you make changes, are you seeing progress in those? Because…and we’ve talked about this a lot before, and we’re going to do a whole episode on like the healing journey and everything. But when we’re thinking about making nutrition changes, you’re not going to see results right away. It takes time. And when you’re doing things, when you’re playing the long game and really looking at more, how your cells are working, like, how are your cells able to make energy—which is what metabolism is—it is so helpful to have things like basal body temperature and pulse to know are things starting to move in the right direction for you. 

So your basal body temperature, this is your temperature first thing in the morning before you get out of bed. And this is really giving you insight into how much energy is your body able to produce. So the lower your body temperature, the slower the metabolism. You want to do it first thing in the morning, because that’s when you’re at rest, right. So throughout the day your temperature will hopefully increase, especially after you eat it should increase. Just looking at your body temperature, you want to look at basal body temp. And one of the big things that it’s also giving you insight into is thyroid function, because our thyroid hormones regulate our body temperature by increasing how much energy is available. So they’ll increase our appetite, our pulse, the amount of oxygen that gets delivered to different parts of the body, how much fat we’re storing. And those thyroid hormones work together with our nervous system to maintain all of that. And so if we have an underactive thyroid, those people are actually shown to generate three times less heat. So that’s why one of the most common symptoms of a sluggish thyroid is feeling cold frequently, right? Like cold hands and nose, those are probably the most common ones, but just being cold in general.

So if you take your temperature first thing in the morning, before you get up…you can use any thermometer, you can get a basal body thermometer if you want, I will put a link for one in the show notes. As long as you’re using the same one. If you are using this for birth control, like fertility awareness method, get a basal body temperature. But if you just have a regular thermometer at home just use that. So you want to place it underneath your tongue for at least a few minutes. If you’re seeing really low temps, it’s probably because the thermometer hasn’t warmed up, hopefully. So the goal is that you take that temperature first thing in the morning. During your follicular phase it’s, the ideal range is 97.2 to 97.8. And then after you ovulate, if you are ovulating, then you would want your temperature to be ideally above 98, around 98.4, as an average. Sometimes it’s going to be a little below, sometimes it can be a little bit higher, those are optimal. The whole point of tracking is so that you know what your normal is. And then as you make nutrition and lifestyle and supplement changes, you can see how that’s improving.

Mid-Episode Ad 26:26
Hey, Amanda here, just giving you a quick break, hopefully a break for your brain in the middle of this podcast episode to remind you that if you haven’t gone through our free training, Optimizing Hormone Health Through Mineral Balance, we really do recommend starting there. And the main reason for that is because you’re going to hear us say things like mineral foundation, having a solid foundation, are you putting the foundations in place, especially as we get deeper and deeper into different hormonal topics and specific imbalances in the body. The mineral foundation is always going to be so essential. So if you haven’t watched the free training, you can find it in our show notes or you can go to hormonehealingrd.com and it’s going to be right on that front page there. But we really recommend starting there so that you can understand how is your current mineral status, how do you assess this, and how to get started with all that just so you can get as much as you possibly can out of the rest of the podcast episodes. But that’s it. I hope you enjoy the rest of this episode.

Emily: So if you’ve heard that a low pulse is healthy, which a lot of people I feel like have…I was one of these people. I thought that having a pulse in the, you know, the low 60s was a really good thing. And that’s probably because a lot of athletes or people who do physical, intense physical workouts or training typically do have lower pulses. But if you think about it, this actually is not great for long term health, because a low pulse tells your body or tells us your body has become more efficient, which means it’s using less energy to perform the same amount of work. But in the long term, this can slow down your metabolism so that your body is compensating to keep up that amount of efficiency, right. So while it’s helpful in the short term, for someone like an athlete, this is not a good thing to experience in the long term. So we do want to kind of see our pulse more at that like 75 to 85 beats per minute range to indicate a good healthy metabolism.

Amanda: And I would just say like, again, start tracking your pulse and see where you’re at. I was at like 40 when I started, so don’t feel bad if yours is really low and don’t feel the same thing with your body temperature. It’s not meant to scare you. It’s meant to give you information. I think that’s the thing we’re all craving. We’re all looking to other people to tell us what to do when if we just start paying attention to our bodies, they will tell us. And I was definitely an athlete that had an extremely low pulse. My body was incredibly efficient at using a lot less energy. But I will say it did not help my hormones at all. And I think that is the one thing that made it incredibly difficult to recover from that super burnout.

And I have plenty of athletes that increase their resting pulse by eating enough food and eating regularly, not going long periods without eating. Their bodies already have enough stress from either the sport that they’re actively playing in. Or if they’re just someone that really enjoys certain types of activities. I have lots of clients that are like super outdoorsy, they love like mountain biking, hiking, they want to be able to do these things, and they can still get pulses up to the 60s and 70s doing this, it just takes a little bit longer. But those are usually the people that see the biggest change and they’re like wow, I’m recovering better. I can tolerate the heat better and different types of extremes when they are exercising. So those are two markers that I would start tracking and see where are you at. And then as you make changes, you can monitor these and see how are they improving over time. Sometimes you’ll even notice, like, after doing a certain type of workout or travel or something, you’ll see that these numbers might go down. And that’s okay. It’s, it’s another way to just say, like, okay, maybe I will take a rest day today, or I’m gonna scale back on what I had planned, because I did a pretty intense workout yesterday, and I had a busy day…took more outta me than I thought. So those are just great markers to have for yourself. 

Some other areas that we do want to touch on before we wrap this up and move on to part two in the next episode, are some common mineral imbalances of PCOS and some lab, the lab testing that we recommend. Because I think this kind of brings it all together, you know, because we’re talking about this spectrum and where you fall in this and starting to track your temps and pulse and your metabolism. If we think about what are some of these imbalances that could be pushing us in that direction? If you have listened to our free training, where we talk about hormone testing versus mineral testing, we’re always talking about minerals are the why. And so if we can start to look more at that, and that I mean, I think hair tests are the best thing for people with PCOS, because then we get to see what is driving your metabolism. Do you have any imbalances that are making it really

Amanda Montalvo

Amanda Montalvo is a women's health dietitian who helps women find the root cause of hormone imbalances and regain healthy menstrual cycles.

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