PCOS: What are the treatments?

In the last blog post you learned all about what PCOS, what causes it, and how it is diagnosed. Now I will discuss the treatment including diet, lifestyle factors, and fertility treatments. Lifestyle factors can improve hormone dysfunction and regardless of whether you are trying to get pregnant, having your body function the best that it can is important.

Diet

Diet is something I am passionate about as a nutrition major, master in clinical research, and I love evaluating studies when it comes to diet. However, when it comes to diet and fertility it is difficult to study. Lots of factors come into play and it is hard to control. The vast majority of our studies are observational. We take people and see what they have and have not done and determine the outcomes.

Carbohydrates

In typical Natalie fashion, I am going to start with the most controversial. Do I think carbohydrates are controversial? No. However, so many people have skewed perceptions about them. Carbohydrates are important components of a human diet. Both the quantity and the quality impact your insulin sensitivity and metabolism of glucose. Whole grains are antioxidants, have anti-inflammatory properties, and they have fiber which has beneficial impacts on how your body processes glucose which lowers insulin resistance associated with improved live birth rates in natural fertility and IVF studies. That alone should be all that I have to say about that. They are healthy.

Low-Carb Diets

There is so much out there about low-carb diets and keto that I am going to say this. Being in a state of ketosis is a state of weight loss. You heard me say that obesity and being overweight amplify the problems you see with PCOS. Losing weight can be beneficial, and ketosis can help you lose weight. However, we have not associated the long term use of a ketogenic diet with improvement in pregnancy rates. One study actually showed a decrease in success with IVF meaning less eggs were retrieved or fewer pregnancies in women that had gone on a keto diet between cycles. A low-carb diet can be associated with a fast track to weight loss and this is mostly because it is the only thing pulling patients of a standard American diet. Any diet where you are limiting sugar and processed foods is going to result in weight loss. It is not that whole grain carbs are bad for you, but that you are eliminating other foods. The old dogma for PCOS was “lose weight at any cost.” Weight loss can help, but it is more than just losing weight. The quality of what you are putting into your body matters.

Animal-Based Protein

Studies that has shown us that every serving of protein that has come from a plant-based source over an animal source, women had higher rates of ovulation. Similarly, embryo development in IVF cycles has been shown to be lower in higher consumption of meat especially red meat. This study was in all patients. Other studies looking at insulin resistance has shown us that protein from animal protein shows an increase in insulin resistance and is highly inflammatory to the body. There is also a big study with AGEs (Advanced Glycolation endproducts) and your diet consumption. Getting AGEs from meats is one of the number one dietary sources. AGEs can cause cellular damage, inflammation, and insulin resistance. In PCOS patients I recommend lowering your meat content by leaning towards a whole food plant-based diet and eliminating sugars and processed foods. Whole grain carbohydrates are not the same as your processed foods and are ok for you!

Losing Weight

If you are overweight, losing weight can play a huge role in your PCOS symptoms. We know how difficult it is for patients to lose weight especially if you are trying to get pregnant. Studies have shown that even losing a small percentage of your body weight can restore ovulation because fat cells make insulin resistance worse and contribute to this extra imbalance.

Supplements and Medication

Outside of diet and weight loss, I put all of my PCOS patients on Vitamin D. Vitamin D is anti-inflammatory. You are also going to most likely hear your doctor talk about Metformin. It is an insulin sensitizing agent so it is improving the sensitivity of your cells to insulin. This is lowering your resistance to insulin and improving how your body is functioning. It’s important to note that Metformin can cause nausea or diarrhea which usually gets better with time. Not all PCOS patients need to be on Metformin. If you have insulin resistance or metabolic syndrome your doctor will most likely want to put you on Metformin. In some patients, it has been shown to improve ovulation allowing the ovaries to function a bit better. Metformin can also be beneficial for patients going through fertility treatment when we are trying to get them to ovulate. There is also a supplement called myo-inosital that can help with insulin resistance. It is essentially a second messenger in how the body processes sugar. One thing I do NOT like my PCOS patients to use is a supplement called Vitex which is an herb called chaste berry and it changes how your hormones function. It may increase your progesterone levels which is like a birth control. If you are not trying to get pregnant with PCOS I want tor regulate some of your other symptoms, depending on how irregular your periods are, we may talk about putting you on a dose of progesterone every few months to get that lining inside the cup of your uterus to dump out so you have a period. We also may talk about birth control pills. I know we often here talk about birth control masking the symptoms of PCOS, but birth control pills are a great treatment for PCOS. They increase your sex hormone binding globulin (SHBG). So they increase your SHBG therefore lowering your testosterone and your free androgen levels. Birth control pills also decrease the production of LH from the pituitary gland. So you are having less androgens produced and less androgens circulating free in your blood. Another treatment if you are not trying to get pregnant, but you do have clinical androgen signs is Spironolactone. It is an aldosterone antagonist but it also binds the androgen receptor so the androgens cannot act on your tissues. This can cause birth defects if pregnant so you will see us do this in conjunction with birth control pills or other contraception.

What are treatments if you are trying to get pregnant?

I need to make you ovulate. It’s the biggest problem for those with PCOS trying to get pregnant. It’s important to know that it is not the only problem. Because of the metabolic dysfunction and the high insulin resistance there have been associations with PCOS and poor egg quality and higher miscarriage rates. We need to be doing everything we can to improve those metabolic abnormalities. I am a huge believer that before I make you ovulate, I need to make sure that I am not missing something else. I see plenty of couples where the women has PCOS but the male partner has no sperm or her fallopian tubes are blocked. I am not saying that if your OBGYN wants to spend a few months trying to make you ovulate it is wrong, especially if you are young. By the time you get to me, I want to know your history. I love data. You will be mad at me if you just paid money, we tried many months of trying to get you pregnant and it was never going to work.

Presuming everything is normal, our first approach is ovulation induction. We can either do that with oral medications or injectable hormones. Oral medications include Letrozole or Clomid. They work differently. Clomid binds to the brain while Letrozole works peripherally. They work similarly in that they lower the body’s estrogen level. Estrogen is lowered, and this tells the brain that it needs a higher dose of FSH. Then you will have a follicle grow. Clomid had been around longer so it has been the medication we have used for a long time. A study came out comparing Letrozole and Clomid. It showed specifically for women with PCOS there were higher success rates with ovulation induction with Letrozole. A recent study came out in 2019 showing that for some resistant women with PCOS the combination of the two together have improved success rates. We sometimes add on extra treatments with medication such as Metformin, Dexamethasone, using a trigger shot, or progesterone after you ovulate to try to improve the efficacy of the cycle. Injectable hormones are Gonadotropins which means we are actually giving the hormone that causes the follicle to grow and allows the egg to mature (FSH and LH). Gonadotropins can be tough for women with PCOS because finding that magic spot where you ovulate just one or two eggs but not seven eggs can be difficult. The rate of multiples is different with these two different treatments. With oral medications, the rate of having twins is about 5%-8% and triplets is 1 in 300. I have certainly seen triplets with Clomid and Letrozole cycles alone so don’t act like that number is zero. With injectable medications these numbers are higher. The risk of twins is about 20%-30% and triplets is about 1%-3%. The other option we have is IVF which gives us the highest success rates. With PCOS you have a lot of eggs so we are often going to get a lot of eggs at egg retrieval and there are strength in numbers for IVF. It is also the lowest chance of multiples because we control that number by how many we put inside. So if we put one embryo inside you have a 1%-2% chance of multiples due to the embryo splitting. This is the only option for some women with PCOS who are resistant to oral medications or over responsive to injectable hormones.

I hope this gave you some insight and clarity if you are someone with PCOS. PCOS is so prevalent, and I feel very strongly that it is important for patients to do everything they can to take control of this disorder.