Laura Schoenfeld: There are a lot of different things that can be done for high testosterone. With PCOS, it does depend on what the cause of the high testosterone is. I have an article on Chris’s website about something called adrenal PCOS, which I don’t think is an actual diagnosis in the real world. There’s something about fake diagnoses … or I don’t want to say “fake,” but un-medically supported diagnoses that I really like to kind of dig into with things like HPA axis dysfunction and adrenal PCOS, that kind of thing. Basically testosterone can get elevated for a variety of different reasons, and with classic PCOS, where you’re having some insulin resistance and you usually are having cysts on the ovaries, not always. You don’t have to have cysts on the ovaries for it to be PCOS, but there is an overproduction of testosterone by the ovaries in this situation because usually of insulin resistance and elevated blood sugar. If somebody is overweight, if they kind of have that classic PCOS issue, maybe they have cystic ovaries, then generally what I’m going to do there is make sure they’re not overeating carbs. They don’t have to go on a very, very low-carb diet, but usually like 20 to 30 percent of their calories from carbs is a good idea. Make sure they’re exercising. You do get more insulin sensitive with regular exercise, and that can be things like cardio-type exercises or weight training. Usually a combination of the two is really helpful for bringing testosterone down in the classic types of PCOS. Usually for the average woman that’s overweight and has slight insulin resistance and that’s what’s causing their PCOS, the combination of a lower carb intake and increased exercise is going to be really helpful.
That would be with the classic-type PCOS. And there are some nutritional supplements and also some prescription medications that can be helpful. There’s a lot of evidence that metformin can be helpful in helping with insulin sensitivity. I know there’s controversy about metformin. I don’t prescribe medications, so I don’t have a lot of an opinion about metformin either way, but I’ve seen it help in some of my clients. I know that berberine has been shown to be somewhat effective the way that metformin is, so that’s an option if you don’t want to be doing metformin if you’re able to prescribe medication. There are other herbal remedies, depending on what the hormonal imbalances are. I believe saw palmetto is a good herbal supplement to bring testosterone down, so that’s an option. You might also want to look at the balance between testosterone and other hormones. Some people have low progesterone in PCOS, so vitex is an herb that’s used to raise progesterone. I’m trying to think if there’s any other … I mean, really, like I said, for classic PCOS, the goal is to make them super-insulin sensitive. Make sure that you’re getting rid of any sort of autoimmune issues. I mean, usually a lower-carb Paleo-type diet is going to be really good. Maybe limiting dairy, as a lot of dairy has higher levels of hormones in it. If somebody is doing a lot of milk products, they might be getting excessive amounts of hormones in their food. But yeah, like I said, lower-carb Paleo plus regular exercise, a combination of strength training and cardiovascular exercise, is usually a good place to start for the classic PCOS.
I don’t personally use berberine with my clients that have PCOS. I just have heard that it can be a replacement, so if you’re someone that feels comfortable prescribing herbal remedies for PCOS, then that might be one you want to look into as far as the amounts and the duration that’s appropriate. Honestly, a lot of the hormonal-affecting supplements you don’t want to take long term. I know vitex, which is the one that’s supposed to help bring up progesterone, that’s not something people should be on long term either. They should really be taking breaks from those kinds of things and retesting the hormone levels using the DUTCH hormone test to see if there are any changes because anytime you’re doing an excessive amount of hormonal regulation, you can potentially go in the other direction, and it could cause some problems.
Now, just for the other side of that question, Laura, you had asked about high testosterone and PCOS. That article that I was mentioning—and I’m going to make a note to myself that I share that article with you guys—the article about adrenal PCOS is more about how stress can cause elevated testosterone. I’ll share that in the Facebook group, about adrenal PCOS. With stress-related PCOS, you’ll see a lot of slim women or underweight women that have PCOS symptoms. PCOS, again, is a weird diagnosis because it’s called polycystic ovarian syndrome, but you don’t have to have cysts on your ovaries to be diagnosed with PCOS. I’m trying to remember off the top of my head what the three different … let’s see … PCOS diagnosis … I know one is the ovarian cysts, one is either amenorrhea or some kind of menstrual dysfunction, whether that be complete amenorrhea or infrequent periods or an inconsistent amount of periods, so maybe you have irregular cycles as opposed to not having cycles at all. Gosh, I’m trying to remember what the third diagnosis is. If anyone remembers what the third diagnosis for PCOS is, please remind me. For some reason, I’m forgetting what the third possible … Basically you have to have two out of three to be diagnosed with PCOS, either cystic ovaries … Maybe it’s elevated testosterone. I’m wondering if that’s one of them, or elevated androgens. The menstrual irregularities is the other one.
A lot of women that have the adrenal PCOS type do not have ovarian cysts. Some of them have ovarian cysts, but it’s pretty common to see no ovarian cysts in these women, and a lot of times they have either amenorrhea or infrequent periods or just not having regular cycles, and then they have the elevated androgens. They have high testosterone. Maybe they have low progesterone. Maybe they have either high estrogen or normal estrogen, sometimes even low estrogen, but basically a lot of the reason for PCOS in women that aren’t overweight or don’t have insulin resistance or don’t have cysts on their ovaries is actually due to stress.
Stress is a weird term because it doesn’t really necessarily just involve emotional stress. You could also consider undereating to be a stress on the body. That’s something that causes the changes in the menstrual cycle and the hormone production a lot. There are things like excessive exercise that can cause changes in hormones, so you want to make sure that your patients are not overexercising or undereating. I work with a lot of women that have this type of PCOS presentation, and they go online and they look to see what the recommendations are, and it’s all like, oh, low-carb diet and more exercise. So you get these women that are really undereating, really undereating carbs, exercising even more than they were before. They think this is what’s going to help them, and it’s actually making things worse. Making sure that person is eating an amount of food that’s appropriate, maybe increasing their carb intake, depending on how low it is, reducing overexercise, so making sure they’re not doing too much exercise or doing too many intense workouts, really pushing the stress management piece, so making sure they’re doing some kind of regular stress management.
Then for those women, again, there are certain supplements that can be helpful. I really like things like inositol or a combination of myo-inositol and D-chiro-inositol for really both types of PCOS, but for these women that are amenorrheic or having irregular periods, it can be helpful, and it helps with insulin sensitivity as well. Definitely both types of PCOS benefit from inositol. Certain types of maca can be helpful for bringing up …
Oh, there you go. Dalip says criteria are one of anovulation, hyperandrogenism, or polycystic ovaries. OK, so they’re either having irregular or absent periods, high levels of testosterone or other androgens, or polycystic ovaries. I thought it was two out of three, Dalip, but it might be one out of three. Honestly, the diagnosis of PCOS is really not well defined, and there are a lot of calls for a redefinition and kind of an overhaul of the diagnostic criteria.
Anyway, for someone with adrenal PCOS, definitely make sure that they’re eating enough, that they’re managing their stress, that they are exercising appropriately. I like to make sure that they’re getting plenty of fat-soluble vitamins. Vitamin A is really important for good hormone production. Make sure their vitamin D status is good. Really focus on the HPA axis with those people. Make sure that everything that they’re doing is promoting good adrenal function and good HPA axis function and not possibly making that worse. The two different types of PCOS that I typically see; there are going to be very different approaches for each one. Like I said, the overweight-type, insulin resistant-type PCOS, you’re going to do lower carb, more exercise. Somebody who is normal or underweight and either not insulin resistant or the insulin resistance is not because they’re overeating, then you’re going to do more of a stress management, reducing excessive exercise, encouraging adequate intake of food, and certain supplements that can be helpful. Like I said, I’ll share that article. I think I give some supplement recommendations in there, so that might be helpful for people.