PCOS And The Microbiome

Do you struggle with irregular periods, male pattern hair growth and/or cystic acne and wonder if you have Polycystic Ovary Syndrome (PCOS)? You are not alone!  

PCOS is a women’s health condition I see very often in practice as it is the most common endocrine disorder amongst menstruating women. PCOS should not simply be thought of as a hormonal imbalance as it’s associated with other chronic conditions such diabetes, obesity, heart disease, infertility and insulin resistance. Many of the women I see also struggle with gut issues and are surprised to learn how these two imbalances are linked. 

This article will cover: 

• PCOS: what is it and how to know if you have it 
• Gut Microbiome: what it is and how it relates to PCOS 

• How healing the gut can heal PCOS 

PCOS: What it is and how to know if you have it: 

PCOS is a common health concern in menstruating women that has three main features: 

1. Irregular periods: 

a. amenorrhea (complete absence of a period)  

b. oligomenorrhea (having very long cycles, typically > 35 days)

2. Elevated androgens:  

• hirstium is male pattern hair growth usually on the upper lip, jawline, neck, nippes, or around the belly button  
• PCOS-type cystic acne generally presents with several cystic lesions along the jawline, neck, back or cheeks  

3. Polycystic Ovaries:  

*Note: don’t be alarmed, or assume you have PCOS, if your doctor tells you they saw a cyst on an ultrasound. Ovarian cysts are simply follicles that mature during the ovulation cycle. It can be completely normal to see 1-3 cysts on an ovary. It’s the presence of larger quantities that becomes pathological. 

 My doctor didn’t see any cysts on my ovaries and said I don’t have PCOS… 

While the PCOS name suggests the dominant feature is ovarian cysts, it is quite common for women to experience PCOS without them. To receive a diagnosis of PCOS you need to meet 2 of the 3 criteria above. This means that getting an ultrasound may not be necessary for many women who are already experiencing irregular periods and signs of elevated androgens. It also means that a clear ultrasound does not rule out PCOS. 

 Root cause of PCOS 

If you’re reading this article you may have been diagnosed with PCOS, or believe you have it, and want to understand WHY these symptoms are happening in your body. The driving forces behind PCOS are insulin resistance and inflammation, of which both are greatly influenced by the gut microbiome. 

 Gut Microbiome: what it is and why it’s important 

The gut microbiome can be your best friend or your worst enemy depending on the state that it’s in. Humans have microbiomes all over, and within our bodies but the gut houses the largest microbiome. It is home to trillions of bacteria, fungi and viruses that influence every aspect of our overall health.  

 A healthy microbiome has a lot of diversity within it AND the right type of microorganisms that protect the lining of the gut and keep inflammation low. 

 PCOS and the Gut Microbiome 

Changes within the gut microbiome and how they relate to PCOS have been the subject of numerous studies over the years. Consistently, studies show PCOS patients have lowered overall diversity and an imbalance of bacteria in the gut microbiome which is associated with higher levels of androgens and a higher BMI. These gut imbalances are also major risk factors for intestinal permeability, commonly known as leaky gut. Leaky gut happens to be one of the primary drivers of inflammation in the body. Chronic low grade inflammation stimulates our immune system to release inflammatory cytokines that can get into the bloodstream of a person with a leaky gut and then travel throughout the body and cause various problems. With PCOS, these cytokines have been shown to interfere with insulin receptor function and cause insulin resistance.  

 An interesting side note is that PCOS patients have been shown to have an increase in the Bacteroides species in their microbiome. These types of bacteria can affect certain hormones made in the gut that control hunger. Clinically, I often see an overlap of patients on the PCOS spectrum that also have a history of binge eating and this research explains why it’s so hard for some people with PCOS to maintain healthy eating patterns. Their hunger hormones are not working correctly! It also reinforces the need to optimize gut health so a woman’s hormones can heal, and they can experience freedom from destructive eating patterns as well as long term health protection. 

 Healing the Gut to Heal PCOS 

Now that you understand how poor gut health can drive PCOS, I want to ensure you’re empowered with some tools to understand how to heal the gut as part of a comprehensive treatment plan for PCOS. 

 Diet 

Eating an organic, whole foods based diet is an essential foundation to any recovery plan. You cannot out-supplement a good diet so please don’t ignore this piece if you want to heal your gut and heal from PCOS. The gut microbes that are residents in your microbiome rely on fiber to grow so eating fruits and vegetables in their whole form is a key component to helping your microbiome thrive. A plant heavy diet has been shown to alter microbial populations that are consistent with higher levels of short chain fatty acids (SCFA) which consequently lower levels of inflammation. Furthermore, the importance of choosing organic is equally important as chemicals sprayed on grains and produce in the USA, such as glyphosate, contribute to the development of leaky gut. 

 Probiotics, Prebiotics and Synbiotics 

• Probiotics are microorganisms found in fermented foods that confer numerous health benefits when consumed. They are naturally found in fermented foods like kimchi, sauerkraut and pickles and can also be found on the shelves of every health food store around. Probiotics have anti-inflammatory effects, regulate the immune system and have been shown to improve metabolic parameters. A study amongst women with PCOS using probiotics for 12 weeks saw improvements with insulin markers, cholesterol and weight loss amongst the probiotic treatment group. 
• Prebiotics are non-digestible fibers found in foods that help promote the growth of certain microorganisms. Prebiotics can naturally be found in foods such as Jerusalem artichokes, asparagus, berries, bananas, oats, beans, leeks, garlic and chicory root. Prebiotics help induce the growth of some of the most valuable bacteria in our gut microbiome like Bifidobacterium and Lactobacillus. A higher prevalence of these beneficial bacteria helps control blood sugar and cholesterol levels, which are often unbalanced in PCOS. 
• Synbiotics are quickly becoming the fan favorite of supplements as they are a combination of both probiotics and prebiotics. When used together, there is a beneficial effect of augmenting each other’s potential to make positive shifts in the microbiome. A 2021 study found synbiotic supplementation in PCOS women led to a significant reduction in serum testosterone levels and helped potentiate weight loss.  

The problem with conventional treatment options 

In conventional medicine, PCOS is often treated with: 

• Metformin to regulate blood sugar 
• Hormonal birth control to regulate periods 
• Spironolactone to help hirsutism and/or cystic acne 

While these options may work for some women, they do not address inflammation and insulin resistance which are at the root of PCOS for most women. They also come with a host of side effects that can set a woman up for other health concerns down the line. 

Working as a fertility specialist, a major problem I see with the conventional treatment of PCOS is that it does nothing to preserve a woman’s fertility. A common scenario I see in practice is women who were put on birth control as a teendager to manage PCOS. They come to me frustrated and desperate in their twenties or thirties when they are ready to get pregnant but struggling. Because guess what? The Pill does not treat PCOS. It masks it. So unless major lifestyle changes have been made since initial “treatment,” PCOS will still be there when the birth control and other pills are taken away. This can cause delays in being able to get pregnant as you can’t make a baby without ovulation occurring. And we know that there are higher rates of pregnancy complications in unmanaged PCOS patients. 

Treatment of PCOS at a root cause level is not only essential to helping women preserve their fertility but also extremely important in protecting their long term health. Unmanaged PCOS is associated with cardiovascular risks, obesity, diabetes and more. 

While the world of microbiome health is far from simple, we can state clearly that  the gut microbiome impacts every aspect of our health. PCOS is no exception! A comprehensive treatment plan to reversing PCOS must include healing the gut.