Practically Fertile

Episode 13 - The Types of PCOS and Nutritional Strategies for Each

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PCOS is a complicated condition that affects up to 20% of all women of reproductive age.  Its presentation can vary among individuals.  Some women have classic symptoms and some women are shocked to be diagnosed with PCOS.  There are lots of opinions out there, but in this episode, we explore:

  • Possible causes of PCOS
  • The internationally recognized diagnosing system for PCOS
  • Why I think there are only two types of PCOS
  • Nutritional strategies for both types


Follow me on instagram @dradriennewei

Website: www.adriennewei.com

Speaker 1:

Welcome to the Practically Fertile Podcast. I'm Adrienne Wee, doctor of acupuncture and Chinese medicine, functional medicine practitioner and functional nutritionist. I specialize in using an evidence-based method, blending principles of East Asian medicine and modern functional medicine to help women optimize fertility and get pregnant. I believe in a world where every woman who wants to be a mother becomes one. If you're tired of being told that you're infertile and you want to take the right steps to get pregnant naturally and quickly, this podcast is for you.

Speaker 1:

You know, it seems like forever ago when I was diagnosed with PCOS. At the time, my doctor told me that very little was known about the condition and he didn't know if I could get pregnant in the future. And he told me to just take some birth control pills, make it go away and just wait and see what happens, because he didn't know what to do to help me. So I definitely had cysts on my ovaries at the time and also facial hair. Till now, to be honest with you, I'm still struggling with facial hair right above my chin and also right about my lip. It's super annoying, but I was lucky enough that when I was diagnosed I was actually in acupuncture school, so I was able to get it under control with acupuncture and herbs. I was able to regulate my period, never 28 days, but I was finally getting a period on a regular basis, like every 38 to 40 days. And then when I met my husband, we both got acupuncture six months prior to trying to conceive. So when we did actually try to conceive we didn't have a lot of problems. So my story is a little bit different, because I had my struggles before even thinking about having kids. I knew that I had problems because I never took the birth control pill. I do think that birth control pills can mask over symptoms of PCOS, which might be why a lot of people are shocked to hear that they have PCOS after getting off the pill. But there was so little information about PCOS when I was diagnosed and now we know so much more. We have more information, more research data and we understand this condition better and have better treatment options. So here's a fun fact about PCOS. It's actually not a new condition. Doctors Stein and Leventhal first described this condition in 1935. So it's been around since 1935.

Speaker 1:

It's important to note that nowadays it's estimated PCOS affects as many as 20% of women of reproductive age. Globally, it's one of the most common ovulatory disorders that cause infertility. But it's also important to know that many women are still being undiagnosed or misdiagnosed. One of the reasons for this increased prevalence is because of the updates to the diagnostic criteria called the Rotterdam criteria. Based on the Rotterdam criteria, a woman needs to have two out of the three characteristics of PCOS to be diagnosed. So these three characteristics are hyperandrogenism, which is an increased amount of male hormones. Irregular or lack of ovulation this is characterized by cycles longer than 35 days or less than eight cycles per year. And also the third is polycystic ovaries, with more than 20 small follicles on each ovary. This classification method means that there could be different types of PCOS. Prior to this, the National Institute of Health guideline was used, which only included the hyperandrogenism and irregular or lack of ovulation. So the Rotterdam criteria was expanded based on that.

Speaker 1:

So now the international medical community recognizes four types of PCOS Type 1, which is someone who has all three of the symptoms the hyperandrogenism, ovulation disorder and polycystic ovaries. This would be what we know to be the classic type of PCOS. Type 2 is someone with an ovary that has no cysts but does have the hyperandrogenism signs and also ovulation irregularities. Type 3 PCOS is someone with the hyperandrogenism and polycystic ovaries but they ovulate regularly. Type 4 PCOS is the mildest type of PCOS, where someone will present with polycystic ovaries and ovulation irregularities but not a lot of the hyperandrogenism signs. I've seen over the years many different types of interpretation on these four types from functional medicine perspectives, such as adrenal type, inflammation type, insulin resistance type. I'm not knocking on these typing systems at all. I want to share my perspective on this and talk about if it really matters which type of PCOS you have based on recent evidence.

Speaker 1:

Pcos you have based on recent evidence. Studies have found that, regardless of the type, body weight and hormone panels, the majority of women with PCOS have underlying insulin resistance. In one study, in a group of women who had PCOS but normal weight, 83.3% were found to have insulin resistance and in the overweight group, 91% of the women had insulin resistance. So there's not a lot of difference between the women with the normal weight versus women who were overweight. And just for clarification, weight and just for clarification. This is not to say that you have to have PCOS to be insulin resistant. In fact, you can have insulin resistance without having PCOS. Anyone can become insulin resistant at any time. But more on this in just a little bit.

Speaker 1:

Insulin resistance I'm going to start referring to it as IR. Ir is the reason why metformin is commonly used as a treatment for PCOS. I think it's being prescribed way too much and way too often, but I understand that if you're going to do IVF and you have to get the IR under control very quickly, that might be the best option. So, because IR is often associated with chronic inflammation, the majority of women with PCOS will also have inflammation.

Speaker 1:

And what about the adrenal type of PCOS? Yes, and what about the adrenal type of PCOS? I just think that anyone with PCOS or without PCOS, the adrenals are going to be involved, because stress is something that all of us experience on a daily basis. The adrenal glands are hyperactive and they're overworked. And similarly, in Chinese medicine, even if your archetype isn't water and kidney deficiency isn't your main pattern, the kidneys are still working in the background and are still a huge part of overall fertility potential. So I think adrenals are involved in every single case of fertility. So does it matter which one of these types of PCOS you have? As far as management of the symptoms and improving your chances of getting pregnant? Not really.

Speaker 1:

What we do know for sure is that insulin resistance and inflammation are the two common issues that all women with PCOS have to deal with. Managing the IR and inflammation is the key to overcoming PCOS. So, before we get into the details about how IR and inflammation specifically affect PCOS, I want to share something very interesting about the origin of PCOS, because it's still a mystery exactly how someone develops PCOS. We know that genetics is a big component, and epigenetics, and the latest research estimates that up to 70% of women with PCOS have some type of gut dysbiosis. So we're getting there. We're getting closer to discovering the reasons why someone might develop PCOS. But what we do know as of right now is that PCOS possibly was developed because it was a survival mechanism, and this dates back to when we were ancient humans. Less ovulation could mean less chances of having children, and that could actually increase survival. And insulin resistance plays into part of this survival strategy as well, because it can lead to the development of PCOS. Because it can lead to the development of PCOS, and then PCOS can lead to more IR.

Speaker 1:

So how do we become adapt to developing IR in the first place? So, like I said, ancient humans had to deal with a lot of stressors like food scarcity, running away from dangerous predators, extreme weather conditions, when you didn't know where the next meal is going to come from or when you'll get to eat again. Some humans were particularly good at developing insulin resistance. An IR, by nature, is a reversible condition, so that makes sense that under stress, survival was the utmost importance. But when the stress triggers were reversed, then you didn't need to be insulin resistant anymore. And there were some reasons for this, of why insulin resistance is good for survival. First of all, our brains use almost exclusively glucose, so, to preserve the brain, insulin resistance prevents other tissues from using glucose and will save the glucose for the brain. Secondly, insulin resistance helped the body to hold on to fat. This provides the nutrient and insulation that can help to increase your chances of survival. And lastly, becoming IR during harsh conditions will allow your body to adapt to a low-carbohydrate diet in times when fruits and tuber vegetables were not available, and that will force the body to burn fat instead for energy and preserve the glycogen storage in the body in case a rapid escape is needed for whatever reason.

Speaker 1:

So fast forward to present day, where we live in the modern world. Our environment has drastically changed, but our body and brain haven't changed very much. We still have the fire-flight response, we still have the scarcity mentality. That's why PCOS is described by some researchers as this mismatch between the environment and the body and brain's pre-programmed responses. We rarely have food shortages as a developed country. We're not running away from prehistoric predators, but when we're running out the door to rush to places, running on the treadmill for two hours, the body's reaction is the same, which is to prioritize survival even though you weren't in any danger.

Speaker 1:

So back to what I was saying before about how anyone can develop IR. This is why, even if you don't have PCOS, you can still be insulin resistant. In fact, 20% of women in a trial who didn't have PCOS were found to have IR. So more on IR for women without PCOS in another episode. But let's get back to PCOS, okay.

Speaker 1:

Insulin resistance can lead to an increase in male hormones, because insulin actually is part of the process of making testosterone and that can lead to facial hair, oily skin, multiple cysts from forming on the ovaries. That will prevent ovulation and it can cause inflammation, weight gain, many other health problems. In a nutshell, how IR produces inflammation is by affecting the gut microbiome. It causes a reduction in the number of good bacteria, specifically bifidobacterium and lactobacillus, and causes an increased number of bad bacteria. So this imbalance leads to leaky gut where the intestinal lining thins to a point where toxins can literally leak into the bloodstream Toxins like lipopolysaccharides. You can actually find out if you have gut dysbiosis through the GI map test. It's a stool test. I run it all the time and we can actually gather a lot of interesting information, including bacterial imbalance, parasites, h pylori, things like that. So I do think GI map is a really good tool to use if you're just not sure if your gut microbiome is balanced or imbalanced. So how do we fix insulin resistance and inflammation?

Speaker 1:

For PCOS, the first line of defense is diet and lifestyle changes. This isn't just my two cents. This is the general consensus in the international community, backed by lots of research. Okay, what has made a lot of sense to me in treating PCOS the last few years is to categorize each patient with PCOS, regardless of the Rotterdam type, and group them into either lean or overweight. I realize this is hard to talk about because weight is a sensitive topic. I'm not trying to shame anyone, but weight does affect your treatment because the diet plan is different for those that need to lose weight and those that don't.

Speaker 1:

Insulin resistance tends to cause your body to hold on to visceral fat, which is the bad fat, and that is the type of fat that leads to more insulin resistance and other metabolic dysfunctions. So even a weight loss of 5% to 10% can dramatically improve your chances of getting pregnant, because it improves the insulin resistance and lowers the testosterone levels, and that will help to promote ovulation and increase fertility. But lean PCOS is not immune to this. Lean PCOS women also have a high percentage of visceral fat compared to subcutaneous fat, even though they're not overweight and their BMI is normal. I mean, have you ever had a friend who was very thin but always had a larger than normal belly? That is most likely caused by IR. And here's something you might not have realized A hidden sign of IR is high LDL cholesterol. I see this very often. My patient tells me that they have a very healthy diet but the LDL is abnormally high. If this is you, I would suspect insulin resistance. What about from a Chinese medicine perspective? What is the TCM viewpoint on PCOS? Everything we've just learned.

Speaker 1:

Cystic ovaries, long cycles, delayed ovulation, insulin resistance, not able to lose weight these are most commonly associated with the wood and earth archetypes. Not to say that you can't be another archetype and have PCOS, but these are the two most commonly seen archetypes and it makes a lot of sense. Wood archetypes are prone to experiencing cheese stagnation. So imagine around ovulation, when the flow of this vital energy is stuck. That can cause the follicles to grow much, much more slowly and might even prevent the follicle from growing past certain sides. G-stagnation can also prevent it from rupturing. That leads to lots of cysts forming on the ovaries. The wood archetypes typically have the lean type of PCOS. With the earth archetypes the problem isn't qi stagnation, it's qi deficiency. Earth archetypes will experience lots of digestive issues. They're the ones that will have more pronounced symptoms of insulin resistance. They'll most likely be more overweight compared to the wood archetypes.

Speaker 1:

If there are cysts on the ovaries and you're an earth archetype, it's most likely caused by accumulation of phlegm and mucus. Splinchy deficiency leads to a sluggish metabolism which, in Chinese medicine terms, causes your body to process what it can into useful energy and the rest just turns into some type of slush that eventually becomes phlegm-like in consistency. And phlegm accumulation doesn't just cause cysts to form on the ovaries, it's responsible for all sorts of cysts, fibroids, polyps that are found in the uterus and other nodules that are found elsewhere in the body are also caused by phlegm accumulation. All right, so let's talk about nutritional approaches for lean and overweight PCOS.

Speaker 1:

For lean, pcos, studies suggest that weight management is still important, meaning, even though there's no need to lose weight, maintenance of current weight to prevent future weight gain is critical. And that doesn't mean what you eat doesn't matter. The quality and quantity still matters. We want to prioritize lean protein, fruits and vegetables and healthy fats and minimize inflammation-producing foods like processed foods, snacks, fast food and sugary drinks. Even if you're the lucky few that can eat whatever they want and never gain a pound, this is still very important for you to follow.

Speaker 1:

The type of fat that you consume is important, so let me just talk about that for a minute. Saturated fat is a contributing factor to IR, but you shouldn't be afraid of quality protein, like grass-fed beef or grass-fed butter or clarified butter like ghee. These types of foods, although they contain saturated fat, the majority is stearic acid, which does not raise your LDL. They can actually even help to raise HDL, which is actually good for your cardiovascular health. So eating grass-fed is not the same as eating industrialized, mass-produced grain-fed beef. I know that red meat gets a lot of bad reps, so I just want to make sure that you know that For overweight PCOS, weight loss is the top priority.

Speaker 1:

This doesn't mean you exercise until you can't walk anymore and only eat an apple and a salad each day. This will likely cause your body to become more insulin resistant and accumulate more fat, but calorie restrictions might be necessary, or sometimes it could be that you're not eating enough. I do want to make sure that, regardless of whether you need to lose weight or maintain your weight, first thing to do is to figure out how many calories a day is needed to accomplish your goal. There are many calorie calculators out there, and the amount required should be different depending on your age, current weight, height and activity level. Similar to lean PCOS protein, protein protein Protein is one of the most important macronutrients.

Speaker 1:

Protein stabilizes blood sugar, it reduces the insulin spike and also provide amino acids that are needed for proper hormone production and balance that are needed for proper hormone production and balance. So I would like to recommend everyone to skip the high-carb breakfast items like cereal, oatmeal, fruit or smoothies and instead go for eggs, sausage, protein pancakes and things like that. This way, you're starting the day off with lots of protein and fat, you're less likely going to be famished at lunchtime and you're less likely going to be famished at lunchtime and you're less likely going to grab whatever you can, and you'll be less likely to have that afternoon slump and you'll have more energy throughout the day, more steady energy throughout the day. There are two other nutrients I want to mention for PCOS that you need to make sure that you're getting enough, and those are vitamin D and omega-3 fish oil.

Speaker 1:

Deficient vitamin D has been associated with several features of PCOS, like hair growth, ir, cardiovascular disease risk and infertility. And since we're all staying indoors more often now and we're using sunscreen more than ever, we're making less vitamin D from the sun. So if you're deficient in vitamin D, definitely supplement. Omega-3 fish oil is another favorite of mine. I love that supplement Not to be confused with DHA, which is only one component of omega-3. Omega-3 has DHA and EPA, so you need to be taking the full omega-3. Omega-3 reduces the inflammation by balancing the omega-3 and omega-6 ratio and it also has been shown to help balance the estrogen and progesterone and promote ovulation for PCOS.

Speaker 1:

Let me switch gears for one second when it comes to using Chinese medicine for these two types of PCOS. The wood and the earth archetypes would benefit from different types of foods. The earth archetypes digestion is likely weaker. Therefore, foods that are bland and easy to digest will be best versus for the wood archetypes, foods that are cooling in nature would be very beneficial, like leafy greens. Okay, one last thing before I wrap up.

Speaker 1:

I do want to mention that inisotol is considered to be one of the best supplements for PCOS because it's very effective at reversing insulin resistance. I'm not going to get into too much detail on this episode because I want to dive deeper into insulin resistance and how it affects fertility in general, not just for PCOS, and talk about inisotol as well in a future episode. So stay tuned for that. All right, fertile Friend. That's all I have for today. Thank you so much for tuning in and spending some time with me. I hope that you have a better understanding of PCOS, insulin resistance and inflammation, and what your nutritional approaches should be if you have lean PCOS or overweight PCOS. So until next time, take care of your amazing self and remember that you're one fertile cycle away from getting pregnant.