Written by: Danielle DeSimone, Executive Contributor
Executive Contributors at Brainz Magazine are handpicked and invited to contribute because of their knowledge and valuable insight within their area of expertise.
PCOS, or polycystic ovary syndrome, is a hormonal imbalance that impacts roughly one in ten women of childbearing age. Trying to conceive with PCOS may feel daunting since PCOS can increase infertility. However, understanding the root cause of your PCOS and learning how to regulate your menstrual cycle will help set you up for success getting pregnant faster. In this article we’ll dive into the four subtypes of PCOS, insulin resistance PCOS, adrenal PCOS, inflammatory PCOS, and post-hormonal birth control PCOS, along with nutrition and lifestyle hacks you can implement now to manage PCOS symptoms. We’ll also cover special factors to consider when trying to get pregnant with PCOS.
Insulin Resistant PCOS
The most common and best known subtype of PCOS is insulin-resistant PCOS. In fact, women who are diagnosed with PCOS may automatically assume they have insulin resistance, but insulin resistance may not play into the other three subtypes at all! This is why it’s so important to understand which category your PCOS falls into so that you can hone in on the root cause of your hormonal imbalance and work to correct it. With insulin-resistant PCOS, chronically elevated insulin levels increase male sex hormones, called androgens. Women are supposed to have low levels of androgens with the most prominent one being testosterone. However, high levels of testosterone negatively impact other sex hormones that are crucial for conception and pregnancy — most notably, progesterone. To understand how to correct insulin-resistant PCOS, let’s first make sure you understand insulin resistance. Insulin is a hormone that’s secreted by our pancreas in response to glucose, or sugar in the bloodstream. Our blood sugar elevates every time we eat. Insulin is secreted in response to take the glucose from our bloodstream and store it in our cells for future use, hence returning our blood sugar levels to baseline. Or at least, that’s what’s supposed to happen. In the case of insulin resistance, however, glucose is chronically elevated due to suboptimal diet and lifestyle habits. When we have constant glucose in our bloodstream, two things happen: Insulin is secreted constantly, and our cells can’t take in any more glucose because they’re full, preventing insulin from doing its job. Think of insulin in this case as a nosy neighbor who comes around every time you have friends over. She knocks on your door again and again wanting to join the party, but you’ve already got a crowd and don’t have room for one more. So you eventually stop answering the door. That’s what happens when insulin is always “knocking on the door” of your cells when they’re full — they respond less and less, if at all. That means your blood sugar stays elevated, so your pancreas gets the message to pump out more insulin and the cycle continues. Thankfully, there are natural ways you can start managing insulin-resistant PCOS right now. An important first step is balancing your blood sugar to drive insulin levels down, and you can do this by including a source of protein (4-6 ounces of meat, fish, eggs, or legumes), a source of healthy fat (avocado, olive oil, nuts, seeds, grassfed ghee or butter), and a source of fiber (nonstarchy vegetables like leafy greens, broccoli, green beans, bell pepper, tomatoes, Brussels sprouts, etc.) with every meal. This fat-protein-fiber combination is the winning method for ensuring blood sugar does not spike or dip after meals. Include two of these components with every snack. Next, think about implementing some form of time-restricted eating. Not all women respond well to intermittent fasting, and your response is largely determined by other health factors such as your thyroid and adrenal status. Instead of jumping into a 16-hour overnight fast every night, I recommend simply having a 12-hour break between when you end eating at night and begin eating the next day. Rather than a fast, this 12-hour time period allows a rest from digestion to help reset your gut, and most importantly, provides a long period of time when insulin is not secreted and levels can fall. Having regular periods of low insulin (which is not the same as low blood sugar) is crucial for becoming more sensitive to
insulin versus resistant to it. Avoiding grazing and over-snacking can also help drive insulin down between meals, so aim for something like three meals and no snacks, or if you are intermittent fasting, two meals and one snack per day. This does not necessarily mean eating less; ensure that you eat enough and balance your plate so that you don’t need to snack between meals. Finally, lower-carb diets are scientifically proven to be therapeutic for people with insulin-resistant PCOS because carbohydrates have a bigger blood sugar impact than fat and protein. Remember, higher blood sugar means more insulin, so it makes sense that reducing carbohydrates and choosing complex carbohydrates can help you stabilize blood sugar levels. This doesn’t mean you need to go on a ketogenic diet, and in fact, very low-carb diets should be supervised by a health professional. I recommend simply moderating your overt carbohydrates, which include grains and starchy root vegetables, to two half-cup servings per day. If you make a fist with one hand you’ll see roughly how large a half-cup serving is. Eat one half-cup serving with lunch and the other with dinner, and if you are eating breakfast, make it rich in healthy fat and protein with a source of fiber like nonstarchy vegetables or a half cup of berries, but skip the overt carbohydrates. We’re better able to handle glucose in our bloodstream after noon, and avoiding overt carbohydrates with breakfast will help you continue to keep insulin levels low without having to prolong your overnight fast. Stick to whole grains like brown rice and quinoa and starchy root veggies like sweet potato and winter squash, and avoid white carbohydrates, processed flours, and added sugars most of the time.
Adrenal PCOS
The second PCOS subtype, adrenal PCOS, is less known and less common, and unfortunately often misdiagnosed. In adrenal PCOS high levels of adrenal hormones, especially DHEA-S and cortisol, drive up androgens including testosterone. This thwarts other female sex hormones and impacts your menstrual cycle and fertility status. It makes sense that natural therapies for managing symptoms of adrenal PCOS are all about stress management. If you have or suspect you have adrenal PCOS your insulin levels may be normal (and your blood sugar may actually trend low) but you may feel chronically burned out, “tired but wired” when you try to sleep, on edge often, or even neutral towards stressors that you should be reacting to. Most of us in the modern world are “on” all the time and dealing with stress round the clock, sometimes even when we’re sleeping. This is not the way humans were designed to operate; we’re meant to respond to an acute stressor and then quickly return back to baseline. When our sympathetic or “fight or flight” nervous system is in overdrive from constant stress our body’s delicate hormone systems go haywire and we run into problems. If this sounds like you, I first recommend making a list of all of the mental, emotional, and physical stressors in your life. Some may be positive, like being the caretaker for a young child or going for a promotion at work. Some may be negative, such as a toxic relationship, going all day without eating a meal, or an overly demanding boss who yells at you. Are there any stressors, especially negative ones, that you can reduce, eliminate, or outsource from your life? It would be great if we could all live without stress. But because that’s not possible, it’s critical to incorporate healthy tools for managing and releasing stress on a regular basis. A great place to start cultivating positive outlets is to make a list of the hobbies or relaxing activities you really enjoy. These should be activities that make you feel fully present, like an hour could pass by but it would feel like only ten minutes because you’re so engaged. It could be an activity like learning a language, taking a pottery class, walking dogs at an animal shelter, doing yoga, knitting, meditating, reading, or drawing. Aim to practice a relaxing and mindful activity regularly, ideally around the same time every day so that it becomes a habit. I suggest carving out a few minutes for mindfulness at the time of day when you could use it most, such as first thing in the morning if you tend to wake with a racing mind, or right before bed if stress often interrupts your sleep.
Next, be on guard for physical stressors. Common offenders here include chronic lack of sleep, undereating and skipping meals, overdoing exercise, and relying on caffeine or other substances to get through the day. We have the tendency to focus on emotional and mental sources of stress but often overlook simple stressors like going too long between meals or only getting six hours of sleep per night. Best practices for women with adrenal dysfunction include getting minimum 8-9 hours of quality sleep per night, eating within an hour of waking and having a balanced meal or snack every 3-4 hours thereafter, focusing on restorative exercise like yoga, pilates, walking, and light strength training over HIIT and long duration cardio, and swapping your coffee for green tea and matcha which has less caffeine in a form that won’t cause a massive cortisol spike. If you think about it, it’s not possible to heal the adrenals if stress hormones are constantly being secreted. While these lifestyle changes may seem drastic if they’re far from your norm, they’re usually temporary as you allow your body to heal — but you may find you feel worlds better without four cups of coffee per day or training for back to back marathons! In addition to driving up androgens, excessive adrenal hormones have a direct impact on progesterone, a key fertility hormone. That’s because cortisol and progesterone are made from the same parent hormone, pregnenolone. When we have an increased demand for cortisol our bodies will divert pregnenolone towards the cortisol pathway and away from the progesterone pathway through a process nicknamed “pregnenolone steal.” This can happen to any woman under chronic stress, and the resulting low progesterone often impairs fertility by causing a lack of ovulation, irregular menstrual cycles, and increased risk of early miscarriage. We’ll talk about natural ways to boost progesterone later on in this article, but a critical lifestyle change is the reduction and effective management of stress.
Inflammatory PCOS
Inflammatory PCOS is the third subtype and it’s increasing in frequency as more people are impacted by chronic inflammation. With inflammatory PCOS, chronic inflammation causes the ovaries to produce more testosterone vs. estrogen, which leads to sex hormone imbalance. To tackle this subtype we have to first understand the main root causes of inflammation in our modern lifestyles: Poor gut health, chronic stress, and lack of sleep. Of course there are more sources of inflammation, but addressing these three main contributors can often dramatically reduce your body’s inflammation levels. Let’s start with the gut pathway. Intestinal permeability, or “leaky gut” as it’s commonly called, effects the majority of Americans and Westerners and is most common source of chronic inflammation. Every day we’re ingesting inflammatory foods such as gluten, dairy, vegetable oils, and added sugars, we’re exposed to environmental pollutants, toxins, pesticides, and herbicides that irritate our gut, and we’re not usually proactive about ingesting the right foods and supplements for gut health.Our intestinal lining so thin that these common irritants can cause tiny holes just large enough for food particles to pass through the gut lining into the bloodstream. This sounds innocent enough – what harm could a protein molecule, for example, do in our bloodstream? Unfortunately, a lot of harm.
Our immune system sees these food particles as foreign invaders and mounts a full-blown inflammatory response. And when the gut is permeable this happens every time we eat, whether we’re eating inflammatory foods or not. It’s easy to see how a leaky gut can lead to chronic inflammation — and autoimmunity — over time. However, that’s not the only source of gut inflammation. Many of us have gut dysbiosis, which is an overgrowth of bad gut bacteria and an undergrowth of probiotics or healthy gut bacteria. In addition to helping us metabolize excess sex hormones, our probiotics are crucial for keeping inflammation at bay and maintaining the health of the gut lining. For people with inflammatory PCOS an anti- inflammatory whole foods-based diet is the first line of defense. Couple this with reinoculating the gut with pre- and probiotic-rich foods (think a variety of vegetables, kimchi, sauerkraut, yogurt and plant based yogurt, no added sugar kombucha, etc.). From there it’s necessary to
introduce targeted foods and supplements, like bone broth, collagen, and omega-3 fatty acids, that close the junctures in the intestinal lining and soothe an inflamed gut. Chronic stress is a main driver of inflammation because cortisol is a pro-inflammatory hormone. This is not necessarily a bad thing since inflammation is part of our natural acute healing response. As you learned earlier in this article, humans are designed to have occasional high levels of cortisol to help us respond to acute stressors quickly (think: a lion entering our camp). In primal scenarios the fight or flight mode would help us do exactly that — have the energy and strength to fight a threat or the energy and drive to run from it – and then we’d easily return to the anti-inflammatory parasympathetic, or “rest & digest,” nervous system. Chronic inflammation occurs when we’re constantly in fight or flight mode and overproducing cortisol. If this sounds familiar it’s important to implement mindful, grounding practices that activate your parasympathetic nervous system on a regular basis. Take a walk in nature while listening to a guided meditation. Start a morning deep breathing practice. Tack a few minutes of journaling onto your bedtime routine. Driving cortisol down will help reduce inflammation. Sleep is often overlooked when we’re talking about hormonal health, and many women don’t know they need 8-9 hours of quality sleep per night. Those studies that tell you to get 7-8 hours per night for optimal health? They, like most medical studies throughout history, were done on men who are far less hormonally complex than you are! When we experience a lack of sleep once in a blue moon our bodies can recover from the temporary influx of inflammatory hormones. However, when lack of sleep is a regular problem it can cause chronic inflammation. Consistently being underslept will also make you more resistant to insulin which can worsen your PCOS – not surprisingly, everything in the body is interconnected! If you’re not normally getting at least eight hours of sleep per night, figure out what needs to shift so that you can go to bed earlier or wake up later to make this happen. If quality of sleep is a problem, meaning you’re struggling to fall asleep or stay asleep through the night, pay special attention to your sleep hygiene. Optimize your environment for sleep by ensuring the room is dark with no outside light coming in, setting the thermostat to around 68 degrees overnight, and blocking outside noise with ear plugs or a white noise machine. From there, implement a healthy wind down routine to cue your body for sleep by shifting you from the fight or flight mode to the rest and digest mode. An easy way to do this is by ending screen time at least 30 minutes prior to bed - you know that doom scrolling is not doing your stress hormones any favors, and the blue light from your screens is inhibiting melatonin production. Instead, wind down with a relaxing and mindful activity like meditation, journaling, reading, stretching, or a creative outlet such as sketching or knitting.
Post-Hormonal Birth Control PCOS
The last subtype of PCOS is often referred to as post-pill PCOS. However, any type of hormonal birth control can cause it, including hormonal IUDs, the NuvaRing, and the Depo Provera shot. Post-hormonal birth control PCOS happens when we come off of hormonal contraceptives which have been artificially controlling and suppressing our natural sex hormones. When the hormonal suppression ends, women may experience “androgen rebound” as male sex hormones are temporarily elevated while our bodies work to establish natural hormone balance. This is different than women with a previous PCOS diagnosis experiencing symptoms again when coming off of birth control, and unlike the other types of PCOS, this type normally resolves itself with time. I recommend that all people using hormonal contraceptives and coming off of them pay attention to repleting key micronutrients these medications deplete, including B vitamins, Vitamin C, Vitamin E, CoQ10, magnesium, and zinc. Additionally, we can promote healthy hormone balance coming off of birth control by following an anti-inflammatory diet, managing stress, getting plenty of quality sleep, and including regular restorative exercise.
Additional factors to consider when trying to conceive with PCOS
A commonality between all four subtypes of PCOS is that they typically result in irregular menstrual cycles due to the inhibition of progesterone. Healthy progesterone production is impeded by both high testosterone and high cortisol. Progesterone is the female sex hormone responsible for ovulation and embryo implantation, and healthy progesterone levels are critical for normal fertility. In addition to driving down testosterone by managing insulin, cortisol, and inflammation, you can use nutrition to your advantage to increase progesterone naturally.
Vitamin C stimulates progesterone production, so be sure to include plenty of Vitamin C rich foods on a regular basis such as berries, bell peppers, citrus fruits, dark leafy greens, broccoli, Brussels sprouts, and cauliflower. Next, ensure you’re eating enough healthy fats with every meal and throughout the day. The best fats to include for healthy progesterone production are omega-3 fats like wild caught fatty fish (salmon, river trout, mackerel, anchovies, sardines, herring), ground flaxseeds, chia seeds, and walnuts. Try eating 4-6 ounces of wild caught fatty fish two to three times per week and including 2 tablespoons of flaxseeds, walnuts, or chia seeds daily. Focus on getting plenty of other healthy fats throughout the day including avocados, grass-fed ghee, olive oil, nuts, and seeds. Like all sex hormones, progesterone is made from cholesterol, so if your progesterone is chronically low consider increasing high-quality animal fats such as pastured eggs, wild caught fatty fish, gras-fed beef, and grassfed ghee in your diet.
Trying to conceive is especially challenging when your cycle is irregular and unpredictable. In a normal cycle, a woman is only fertile or able to get pregnant for six days out of the month — the five days leading up to ovulation and the day of ovulation. But if you’re not ovulating every month, you don’t have a monthly fertile window, meaning you may only have the chance to get pregnant every few months or a few times per year. What’s more, without regular cycles you may have no idea when you’re about to ovulate, especially since ovulation occurs approximately two weeks before your period. I recommend that women with any type of PCOS get comfortable tracking their LH, or luteinizing hormone, which is the hormone that surges when a follicle ripens to release an egg. LH typically peaks 12-36 hours before ovulation. Because you may not be ovulating regularly it’s a good idea to get in the habit of testing LH daily via at home urine test strips. The best time of day to test LH is in the late morning to early evening. You may find you’re getting multiple LH surges in a short period of time. Unfortunately, many women with PCOS experience more than one LH surge as the body gears up to ovulate, fails, and then tries again. So how do you know when you actually ovulated? LH alone does not mean you successfully ovulated, and to confirm ovulation it’s necessary to test urine or blood progesterone levels roughly seven days after your LH peak. PCOS is a common cause of anovulation, or lack of ovulation, so confirming successful ovulation with progesterone testing is especially important for women with PCOS who are trying to conceive. While you can go to a lab for blood work seven days after your LH peak, you can also test progesterone levels at home via more cost effective urine test strips. Another symptom of PCOS that impacts fertility is its effect on egg quality. Women with PCOS tend to produce more follicles per month, however, egg quality tends to be poorer and less likely to result in a viable embryo. While you work to correct your PCOS and balance your hormones, you can also benefit from focusing on nutrition and lifestyle optimizations to enhance egg quality. One of the most impactful ways to boost egg quality is by getting plenty of dietary antioxidants. An egg is one cell that you’ve had your entire life, and it’s subject to the DNA wear and tear that naturally occurs as we age. Antioxidants protect against this damage by improving cellular cleanup and renewal. You’ll get the biggest bang for your antioxidant buck by focusing on a variety of herbs and spices such as garlic, ginger, turmeric, cinnamon, parsley, oregano, sage, cilantro, rosemary, clove, basil, and thyme. Add a healthy dose of your
favorites every time you cook. Try to include a half cup of berries daily for additional antioxidants, and swap that morning coffee for a matcha which is one of the most potent antioxidant foods on the planet and boasts ten times more antioxidants than green tea! Bonus: Matcha and green tea in general are helpful in metabolizing excess testosterone.
To further enhance your egg quality, make sure you’re minimizing or eliminating substances that have a toxic effect on eggs, including processed sugar, caffeine, alcohol, endocrine disruptors, cigarettes, and recreational drugs.
Take Action
In summary, PCOS can impact fertility and make it harder to get pregnant by interfering with normal hormone balance and impairing egg quality. However, PCOS is reversible and largely impacted by our nutrition and lifestyle choices. Determining the root cause of your PCOS and tailoring your diet and daily habits to promote hormone balance and egg quality gives you better chances of success when trying to conceive. Regardless of fertility goals, everyone with PCOS could benefit from working with a women’s health expert who is well-versed in balancing hormones naturally. As a functional fertility coach I work with women every day to balance sex hormones, improve lifestyle habits, and overcome PCOS to achieve pregnancy. You can schedule a complimentary functional fertility consult with me here to talk about your unique health concerns and get expert support in achieving your health and fertility goals.
Danielle DeSimone, Executive Contributor Brainz Magazine
Danielle DeSimone is a functional fertility, prenatal, and postpartum health coach who has spent nearly a decade empowering women as they step into motherhood. Danielle has spent time in both traditional fertility medicine at the Sher Institute for Reproductive Medicine in Manhattan and in functional medicine at Parsley Health. She is the founder of Shine Total Wellness, a US based women's wellness practice that offers one on one health coaching worldwide via telehealth. Danielle's mission is to empower women to achieve vibrant fertility health and feel supported and confident throughout pregnancy and postpartum.
References:
Brighten, J. Is a Low Carb Diet Good for PCOS? https://drbrighten.com/pcos-low-carb/
Kresser, C. Adrenal PCOS: Surprising Ways Stress EffectsYour Hormones. https://chriskresser.com/adrenal-pcos-surprising-ways-stress-affects-your-hormones/
NIH National Library of Medicine. The Role of Chronic Inflammation in Polycystic Ovarian Syndrome: A Systemic Review and Meta-Analysis. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7962967/
Brainz Magazine. The 3 Secrets of a PCOS Friendly Diet. https://www.brainzmagazine.com/post/the-3-secrets-of-a-pcos-friendly-diet
Verywell Health. Using OvulationTest Kits When You Have PCOS. https://www.verywellhealth.com/ovulation-kit-tips-for-pcos-patients-2616458
