Polycystic Ovarian Syndrome (PCOS) is the most common hormonal disorder among women of reproductive age, affecting an estimated 7–15 percent of women worldwide.
PCOS can be a mystery to doctors and patients alike. The classic signs of this disorder are obesity, acne, irregular periods, and facial hair—yet some women never display these symptoms. As a result, many women may go years without realizing they have PCOS because they don’t have the textbook symptoms.
In PCOS, the ovaries produce higher than normal levels of male sex hormones (androgens) leading to a variety of symptoms, including the development of small ovarian cysts, from which the condition gets its name. If left untreated, this hormonal imbalance can lead to serious chronic health problems, such as diabetes and heart disease.
Dr. Fiona McCulloch is a naturopath practitioner based in Toronto who specializes in evidence based therapies for PCOS, thyroid health, infertility, weight management and other conditions often rooted in hormonal imbalance.
Her upcoming book, “8 Steps to Reverse Your PCOS: A Proven Program to Reset Your Hormones, Repair Your Metabolism and Restore Your Fertility” discusses the science behind the condition, the tests used to identify it, and the variety of treatment options available for women struggling to find relief.
Epoch Times talked to McCulloch about her own experience with PCOS, the importance of diet and exercise in treating the condition, and why many women don’t know they have it.
Epoch Times: Tell me about your own personal experience with PCOS.
Dr. Fiona McCulloch: When I was a teenager I always had extremely irregular cycles and cystic acne. I went from dermatologist to dermatologist to treat my acne, but nothing would ever really work. I was on every kind of antibiotic you can imagine, every type of cream, but it would always come back.
Nobody ever suggested that I might have PCOS at all. Probably because I didn’t appear to have what doctors typically think PCOS should look like.
I gained some weight during my university years, which is pretty typical for college students who eat a lot of carbs. My acne got a lot worse and my cycles were still very irregular. But I thought my cycle was normal, because I wasn’t aware of things at that time.
As I went through school my symptoms persisted. I decided to become a naturopathic doctor and when I went to naturopathic school I started learning a lot about nutrition. I changed my diet quite a lot, and soon my cycles became more regular. It was a huge improvement. The acne was maybe a little better, but it still wasn’t gone.
After I graduated, I became very interested in treating women’s hormonal conditions, and I started realizing that my symptoms matched PCOS. I had an ultrasound which found a lot of eggs in my ovary. When I had the blood work done, it showed I had pretty much all the markers of PCOS. The lightbulb went on and I realized this is what I have had my entire life.
So then I started looking into how to treat it, and I learned that there was quite a lot of evidence for treating PCOS with nutrition, lifestyle, exercise, and supplements. So by the time I turned 30 years old I was able to fully resolve all the symptoms, including the acne.
My symptoms have been reversed, but I know I still have PCOS and I have to be careful because I’m still at high risk for chronic health conditions, such as diabetes, as I age.
Epoch Times: One of the things I found surprising is that, despite the name, some women with PCOS don’t have cysts on their ovaries. I’m curious how that can be.
Dr. McCulloch: When this syndrome was identified, they found that women who had the most severe presentation had cysts on their ovaries. These cysts are really just eggs that haven’t fully ovulated, so they’re not real cysts. They’re not pathologic.
In PCOS the ovulation is stalled, and there’s a lot of testosterone inside the ovaries so the eggs accumulate there. But when women with PCOS do ovulate, they tend to not have as many of these [cysts], or you might not see any of them. But they still may have all the symptoms of the condition.
To diagnose PCOS, you need to have two of these three criteria: Delays in ovulation. Androgen excess. (This is related to high testosterone. This could be either in the blood work or with something like acne or hirsutism, which is facial hair growth.) The third one is the polycystic ovaries. You don’t have to have polycystic ovaries to have PCOS. And, interestingly as well, as a woman gets older she’s far less likely to have polycystic ovaries, because she has fewer eggs. So you see this more in young woman who have it.
The other thing that goes along with PCOS are metabolic symptoms. Women with PCOS have high insulin levels. They tend to gain weight around their stomach, and it is very difficult for them to lose weight. They have a high prevalence of obesity and a high prevalence of developing diabetes. Insulin is what causes a lot of the hormonal imbalances.
Underneath all of this is chronic, low-grade inflammation, and this can be the cause of insulin resistance. A lot of what they’re learning now is that women with PCOS have fat cells that are dysfunctional and more inflammatory. Even really slim women can have fatty tissue dysfunction.
Epoch Times: PCOS is the most common hormonal dysfunction in women. What makes it so prevalent?
Dr. McCulloch: It’s a combination of genetics and environment.
There are many genes that have been strongly linked to PCOS and a lot of those genes go along with metabolic conservation, so in times where there wasn’t enough food these women would do very well, because they were good at conserving energy. This is why they think that this condition has persisted, despite the fact that it reduces fertility.
One of the things we’ve learned recently is that there’s a really strong link to environmental hormonal disruptors in PCOS. So if a woman is pregnant and exposed to environmental toxins, like for example Bisphenol A (BPA), that may be related to the child developing PCOS. For instance, they have been able to induce PCOS in rats by exposing them one time to BPA while they’re developing in the womb. They also find that teenage girls with PCOS excrete a lot more BPA from their urine. There is definitely an environmental link, and potentially it’s an aggravating factor.
We don’t know for sure what causes it, but we do know that all these things are linked to it. It’s quite complex.
Epoch Times: You write that “PCOS is probably the women’s health condition that responds the best to dietary changes. In some cases, nutrition alone can reverse most symptoms.” Why does diet play such a large role in PCOS?
Dr. McCulloch: The reason is that insulin resistance aspect is central. Basically, high insulin levels cause the ovaries to create testosterone.
Whenever we eat, blood sugar goes up and insulin is released in order to deal with the blood sugar. But there is a higher amount of insulin released in PCOS and it is released for longer as well, so there’s just a lot more insulin in the body. By eating foods that cause us to secrete less insulin, you can see huge improvements in this syndrome.
Epoch Times: In regard to identifying insulin lowering foods, I’ve heard of the glycemic index before, but you use something called the insulin index. What’s the difference?
Dr. McCulloch: The glycemic index shows how much your blood sugar rises after you eat. The insulin index is developed by the same people who did most of the research on the glycemic index at the University of Sydney. What they found is that there are certain foods that raise insulin, but don’t raise blood sugar. This is a wow moment. It lets us know how much certain foods raise your insulin after we eat.
In my book I’ve developed a program based on choosing foods and combining them in a meal to control the amount of insulin that’s released after eating. It’s an insulin control diet, so it gives women the tools to be able to measure the amount of insulin they’re releasing and to keep it low.
It’s a point system where they can choose among proteins, vegetables, and healthy fats. The carbs are at the very end. Generally, they get a palm-sized piece of protein, two-thirds of a plate of vegetables, one tablespoon of a healthy oil, an avocado, or a closed handful of nuts, and a carbohydrate. The carbohydrate amount will differ depending on a woman’s level of insulin resistance. Some do better on a very low amount, and some need a little bit more, but it allows them to quantify that.
I have had a lot of success with this diet and it’s really easy to follow. It’s what we’ve found to work, but there’s a lot different nutrition plans can work for PCOS.
Definitely they should avoid sugar, and dairy. Dairy has actually found to have the most insulin stimulating proteins. It’s shocking because we’ve all been given this advice to eat a lot of yogurt. In my case, I always knew that dairy would make my acne break out severely. We used to think that it was maybe related to the hormones in dairy, but we weren’t sure why it was happening. Now it’s really clear.
Epoch Times: What role does exercise in PCOS recovery?
Dr. McCulloch: Exercise is one of the most helpful things you can do for PCOS, especially muscle and weight training. Any kind of exercise is helpful, but the more muscle mass or lean muscle that a woman has the more insulin sensitive she becomes, so it really improves that insulin resistance all the time.
Epoch Times: It’s great to hear that the two most important things in treatment, diet and exercise, are things women can do for themselves.
Dr. McCulloch: It really is amazing. It’s just a matter of learning what to eat and finding a nutrition plan that can fit into your lifestyle. Our nutrition plan can also prevent Type 2 diabetes and cardiovascular disease. The more information about this women have when they’re first diagnosed the better.
Epoch Times: You write that many women don’t even know they have PCOS. How is this condition elusive to doctors and patients?
Dr. McCulloch: It is really common for women to not know. A lot of times they don’t find out until they have trouble getting pregnant. When they investigate, it turns out they have PCOS. But I’m sure there are women who go their whole life and never know they have it.
The reason it’s elusive is because it presents in so many different ways. If doctors haven’t seen enough presentations of it, they may not notice it in a woman who doesn’t have that classic type of PCOS they expect to see: quite heavy with facial hair.
Testosterone levels are another thing. A lot of people expect to see high blood testosterone levels in women with PCOS, when actually most women don’t have that. One reason is that the normal reference ranges for testosterone have been created including women with PCOS. The other reason is that testosterone levels decrease with age. So it’s really only in very young women with severe PCOS that will have high testosterone. A lot of the time women are told they can’t have PCOS because they don’t have high testosterone.
Another thing is with the insulin resistance markers. A lot of the time what is being tested are actually markers for diabetes. I can’t tell you the number of times I’ve had women come in and say, “Well, my glucose is normal so I don’t have insulin resistance.” But high glucose only happens after many, many years of insulin resistance, and that’s when the pancreas can no longer handle the glucose.
They should really be testing fasting insulin levels. Women with PCOS often secrete a lot more insulin, and they secrete it for longer, and it’s a lot different than in women who are not insulin resistant. It’s really a matter of the right test to order.
Epoch Times: Going back to the women who do have the classic overweight presentation, you write that women often hear from their doctor that if they just slim down they will feel a lot better. Why do you think this isn’t such great advice?
Dr. McCulloch: For so many reasons. First of all, if someone is going to be told to just lose weight, they need to be armed with the information to do that because it is not an easy thing. There are plenty of studies that show that most people who lose weight gain it back again.
We all know that there is something about weight loss that is not easy. Depression, anxiety, low self esteem—all of these emotional conditions are so common in PCOS—so hearing that they just need to lose weight makes women more depressed and feel like they’re being blamed.
It is actually harder for women with PCOS to lose weight because they have such high insulin. One of insulin’s jobs is to put sugar into the cell and store it as fat. Another job is to stop fat breakdown. If we’ve just eaten, obviously our body is not going to start burning fat for fuel at that time. That’s why if you have high insulin all the time it’s harder to burn fat.
In PCOS there is a particular problem that we have to address: how are we going to lower their insulin so they can lose weight more easily, so it’s not this huge struggle that makes them feel like they can’t succeed?
The best way to approach it is to provide the tools, information, and support they need, and be encouraging to make those dietary changes. Don’t focus on the numbers on the scale. Focus on lowering their insulin. Women usually do lose weight when that happens and they’re able to keep it off because they now have the tools and they feel positive about it. This is about treating a woman as a whole person and realizing that this is not a choice but a medical condition.
Epoch Times: In regards to giving women the tools they need to understand this, one of the things that struck me about your book was how comprehensive and detailed you got in describing the biology behind this condition and the tests used to identify imbalances. Why make such a detailed book? Why not just say, “If you want to get better, just do these things?”
Dr. McCulloch: Part of the reason I did that is because I wanted women to use this as reference manual. They could have the information they needed when they talked to their doctor, and when they get blood tests they can look that up and understand as much as possible about their body.
In PCOS it really is about a woman making changes for herself and empowering her to that. I think it is very empowering to understand what’s going on in your body and be able to see changes in your blood tests as signs of improvement. Patients really want to know what these blood tests mean. So I am hoping to provide a trusted source so that women have the facts they need.
Epoch Times: Your book discusses both natural and conventional treatments for PCOS. Are there any advantages of one kind of treatment over another?
Dr. McCulloch: I think both approaches are helpful in various situations and at different times in a women’s life. When you’re going for fertility treatment, for example, you may need assistance from a medication. There are pros and cons to every type of treatment and every situation.
For example, Metformin— which is probably the most prescribed medication for PCOS aside from the birth control pill—can cause a lot of gastrointestinal side effects that many women don’t really like. But there are some women who have conditions that are quite severe, and they actually do very well on Metformin. For women who can’t tolerate Metformin, some of the natural supplements, like inositol, work just as well without the side effects.
I know the birth control pill helps a lot of women with PCOS, but it also masks the symptoms of the condition, which is why a lot of women go undiagnosed. They will have irregular periods when they’re young, they’ll go on the birth control to deal with that, but they never really see their hormones after that point in time because they’re getting regular periods. When they come off of it and try to have a baby, that’s when they learn they have PCOS, but maybe they would have been aware of it earlier if they weren’t on the birth control pill.
The other problem is that birth control pills have an increased clotting risk which women with PCOS are already prone to.
There are other ways to deal with symptoms that are preferable. So I think an integrative approach where different kinds of treatments are used with awareness. A woman should consider what she wants to take and how it will affect her body.
Epoch Times: It definitely seems like there is not a one-size-fits-all approach to treatment.
Dr. McCulloch: Exactly. And at different times in a woman’s life the treatment will be different as well.
Epoch Times: What else would you like people to know about PCOS?
Dr. Fiona McCulloch: One thing I want to point out is that when women go through menopause, the PCOS is still there. I think a lot of the time that’s forgotten and so the treatments just stop. But actually, all of the metabolic syndromes and diabetes risk gets worse with age.
Just like other chronic diseases, cardiovascular disease and Type 2 diabetes, PCOS is a huge public health concern and it’s not getting much research. It gets 0.1 percent of all funding from NIH. The fact that it affects seven million women in the U.S. alone means we need to increase the awareness of this so that women can identify it and treat it properly. That will make a huge difference for the overall health of women everywhere.
McCulloch’s book will be available for purchase on September 21, 2016