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It’s well known that stress can cause the disruption or total loss of menstrual function in women. (1) And menstrual dysfunction, along with the physical symptoms of hormone imbalance, has become increasingly common over the past few decades.
It’s now estimated that up to 10 percent of reproductive-age women in the US have polycystic ovarian syndrome (PCOS), a health condition that not only affects a woman’s fertility, but also causes frustrating changes to her physical appearance, including weight gain, male-pattern hair growth, acne, and water retention.
And while there certainly is a genetic component that increases one’s risk of the syndrome, PCOS is significantly affected—and possibly caused—by lifestyle factors including diet, exercise, and stress.
Unfortunately, in an age where high achievement and perfectionism are idolized and flat abs and “thigh gaps” are considered to be the standard of feminine physical beauty, there are thousands of women running their bodies and hormones into the ground in an attempt to lose weight and achieve this impossibly high cultural standard.
I’ve worked with dozens of women who were undereating, overtraining, and under constant stress and even fear related to their poor body image and a desire to be thinner and leaner by any means necessary.
Sadly, this extreme diet and exercise behavior can backfire when women start to develop “adrenal PCOS”: the elevation of androgenic hormones by the adrenal glands that causes symptoms similar to ovarian cyst-driven PCOS.
In this article, you’ll learn how excessive stress about your diet, exercise, and life in general might be driving the adrenal hormone changes that are causing your PCOS symptoms.
Myths and Truths about PCOS
There are many misconceptions about PCOS that cause confusion, misdiagnosis, and mistreatment in women who are experiencing the multitude of symptoms associated with the disorder.
Despite the name polycystic ovarian syndrome, having cystic ovaries isn’t a requirement to be diagnosed with PCOS.
In fact, the NIH has concluded that the name PCOS should be changed, as the name causes confusion and doesn’t reflect “the complex metabolic, hypothalamic, pituitary, ovarian, and adrenal interactions that characterize the syndrome.” (2, 3)
Many people, including healthcare professionals, also don’t even realize that being overweight is not a requirement of having PCOS. It’s estimated that one-third to one-half of women with PCOS are at normal weight or underweight and that being overweight or obese does not increase the risk of developing the condition.
While weight loss in women who are overweight may be beneficial, this recommendation isn’t useful for women with PCOS symptoms who aren’t overweight. And using birth control pills as a treatment for amenorrhea is often unnecessary and simply masks a deeper diet and lifestyle problem.
Elevated Androgenic Hormones: Not Just an Ovarian Problem
One of the primary diagnostic criteria of PCOS is elevated androgens, “male” sex hormones that cause unwanted hair growth, acne, and reproductive dysfunction.
The two main androgenic hormones causing these symptoms in women are testosterone and androstenedione. Other androgens include dihydrotestosterone (DHT), dehydroepiandrosterone (DHEA), and dehydroepiandrosterone sulfate (DHEA-S).
It’s normal for women to have some androgenic hormones in their system; in fact, low testosterone in women is associated with low sex drive, bone loss, chronic fatigue, weight gain, mood disorders, and cognitive issues. Calling them “male” sex hormones is a misnomer.
However, when these hormones are elevated, as is pervasive in PCOS, symptoms of androgen excess begin to manifest. For some women, this affects their menstrual function and fertility. For others, they continue to menstruate but struggle with physical changes like unwanted hair growth, acne, and weight gain.
And one of the primary confusions over PCOS is which organ these androgens come from. While the ovaries are typically blamed for elevated androgens in PCOS, it’s estimated that 20 to 30 percent of women with PCOS have adrenal androgen excess. (5)
The adrenal glands produce all of the DHEA sulfate (DHEA-S) and 80 percent of the DHEA in the body. The adrenals also produce 50 percent of androstenedione and 25 percent of circulating testosterone. Since DHEA-S and 11-androstenedione are not secreted by the ovaries, they are used as markers of adrenal androgen secretion. (6)
How Your Adrenals Cause PCOS Symptoms
The chart below shows how both the adrenal glands and the ovaries impact androgenic hormone production. It illustrates how the hypothalamus and pituitary gland, both located in your brain, release hormones that drive the cycle of high androgen output, insulin resistance, increased abdominal fat, and impaired glucose sensitivity. These systems are called the hypothalamus-pituitary-adrenal or -gonadal axes. (HPA/HPG.)
While insulin resistance and elevated insulin often drive the ovarian production of testosterone, it is the hypothalamus-pituitary-adrenal (HPA) axis that stimulates the production of DHEA/DHEA-S and androstenedione. These hormones can be converted to testosterone by peripheral tissues in the body. This process can occur independently from the ovaries and any involvement with insulin.
This means that a woman with PCOS symptoms could have normally functioning ovaries with no cysts and no insulin resistance, yet still fit the symptomatic profile of the syndrome.
There is some controversy over whether elevated androgens cause insulin resistance or if insulin resistance happens first. The most likely answer is “it depends”; some women likely develop insulin resistance first, while others develop elevated androgens first.
Either way, it’s clear that not only is the brain heavily involved in the output of androgenic hormones, but that the adrenals may also be responsible for PCOS symptoms in a subset of patients.
How Stress Impacts Your Hormones
The pituitary gland, stimulated by the brain via the hypothalamus, secretes adrenocorticotropic hormone (ACTH) in response to stress. ACTH then stimulates the adrenal glands to produce cortisol, adrenaline, and noradrenaline. In addition to these stress hormones, ACTH also stimulates the production of adrenal androgen hormones, including DHEA, DHEA-S, and androstenedione.
ACTH follows a diurnal rhythm, meaning it’s higher in the morning and lower in the evening, but it also spikes in response to physical and emotional stress. Stress activates the HPA axis, raising ACTH and cortisol output. Cortisol release then down-regulates ACTH production in a negative feedback loop.
ACTH also stimulates the production of DHEA/DHEA-S and androstenedione, which help protect the brain from the negative effects of cortisol and other stress hormones. (7) But as you learned earlier, these hormones also cause the symptoms of elevated androgens seen in PCOS.
And these androgenic hormones do not affect the release of ACTH, unlike cortisol, meaning there is no feedback regulatory loop that controls androgen secretion in women. (8)
Research also shows that women who are under extreme chronic stress situations (for example, PTSD) have a markedly increased DHEA response to ACTH stimulation, as well as a higher ACTH response to stress and stimulation from the hypothalamic hormones. (9) They also have higher levels of baseline DHEA compared to healthy controls, and traumatized women with the highest DHEA had the least severe PTSD symptoms.
Where Does Chronic Stress Come From?
To review, you’ve learned so far that:
- Elevated androgens like testosterone and androstenedione contribute to PCOS symptoms like menstrual dysfunction, unwanted hair growth, weight gain, acne, and mood disorders
- The adrenal glands are responsible for at least 20 to 30 percent of the elevated androgens seen in PCOS
- Chronic stress elevates ACTH, which stimulates androgen secretion, for which there is no negative feedback loop
- Androgen hormones are protective against the long-term effects of chronically elevated stress hormones like cortisol and adrenaline
I hope it’s perfectly clear by now that chronic stress is a major contributor to the development of PCOS symptoms, especially in normal or underweight women with non-cystic ovaries and normal insulin sensitivity.
Elevated androgens, while causing PCOS symptoms, may be the body’s way of protecting the brain from the harmful effects of chronic stress.
And chronic stress is everywhere these days; from long work weeks and poor sleep to new babies and aging parents, to constant negative thoughts about our bodies and physical appearance, women are bombarded by stress from every direction.
Combine this with traumatic events, acute illness and infections, gut dysbiosis, and disrupted sleep, and it’s no wonder that so many women come to me complaining of reproductive dysfunction or amenorrhea, weight loss resistance, blood sugar fluctuations, anxiety and/or depression, acne, chronic fatigue, and hormonal imbalances.
The worst part is that the more stress drives up our androgenic hormones, the more our weight, skin, and hair growth is affected, and the harder we struggle to improve our appearance.
For some women, this drives them to restrict their diet further, diet harder, work out more often and more intensely, and push their bodies to the brink of exhaustion. It’s a vicious cycle that I see all the time in my practice. (I’ve even struggled with this problem myself.)
Don’t get me wrong: there are plenty of women whose PCOS is caused by a poor diet, inadequate exercise, too many refined carbohydrates and sugars, and a generally unhealthy lifestyle.
How to Kick Stress to the Curb
Getting your stress under control is a challenging task, and unfortunately, there’s no quick fix for the long-term effects of regular stress. Our culture thrives on stress and perfectionism, and many people push themselves past their physical limits in an attempt to “look better naked,” make more money, have more possessions, and live an envy-worthy life that looks great on Instagram.
If you’re ready to break the cycle of stress and fear-based health pursuits, here are a few tips to get you started in the right direction.
As I explained before, many conventional recommendations for PCOS involve losing weight and increasing insulin sensitivity, primarily through reducing carbohydrate intake, cutting calories, and increasing physical activity. These recommendations work well for the woman eating a typical American diet and not moving enough.
But if you’re already eating a low-carbohydrate Paleo diet and your symptoms are getting worse instead of better, you might be a woman whose body is responding negatively to the stress of inadequate calorie and carbohydrate intake.
First, start by assessing your total calorie intake. One benefit of a Paleo diet is a spontaneous reduction in calorie intake, but for women who are active, this can take their intake too low to support their exercise routine. Combine this with poor body image and a desire to lose body fat, and many women are taking their food intake even lower, either consciously or unconsciously.
Chronic calorie deficits over a period of months or years raise stress hormones as your body tries to conserve energy and keep blood sugar stable. Make sure you are not eating less than 80 percent of your estimated calorie needs on a daily basis if you are trying to lose weight, and consider taking a break from any calorie deficit for a few weeks or months.
Too little carbohydrate intake can have similar impacts as inadequate calories, especially for highly active women doing glucose-demanding activities like weightlifting and CrossFit. Use this article to guide your carbohydrate intake depending on your health needs and activity levels.
Eating a calorie-appropriate and macronutrient-balanced diet is a huge step for many of the women I work with in my private practice to improve their hormonal profile.
Again, the typical recommendation for a woman with PCOS is to exercise more. But if you’re already hitting the CrossFit box five days a week, running 20 miles a week, or squeezing bootcamp classes in at 5:30 a.m. every morning, you might be damaging your hormones by exercising too much.
If you’re concerned that overexercising is driving your hormonal imbalances, check out this article on exercising with “adrenal fatigue” (HPA axis dysfunction) for guidelines on how to appropriately scale back your exercise so that you’re maintaining strength and fitness while allowing your hormones to recover.
Admittedly, sleep is one of those health behaviors that I still struggle to prioritize. And yet the benefits to my energy, performance, and cognitive function I experience when I get adequate, high-quality sleep are undeniable.
One of the most common factors impacting our ability to sleep well is our use of electronic devices after the sun has gone down. Check out the guidelines in this article for ideas on how to mitigate the effects of light exposure at night so that your sleep is more restorative.
And if you’re having trouble falling or staying asleep, review your diet and exercise program. Many of my clients with sleep difficulties find that stopping any excessive high-intensity exercise and eating adequate calories and carbohydrates help them sleep far more soundly and wake up feeling refreshed.
There are dozens of different techniques that can help reduce stress on a daily basis. Some of the more well-known recommendations include things like meditation, deep breathing, yoga, and tai chi. These ancient practices are effective tools that reduce stress hormones, and meditation in particular is one that can easily be done daily.
However, there are countless other options for reducing stress, so pick one that works best for your personality and your life. That might mean you get a pet like a dog or a cat, start volunteering regularly, join a spiritual/religious community like a church or synagogue, join a meetup group, or even start coloring! (I love these coloring books!)
Whatever your stress management practice is, commit to doing it regularly. Meditation isn’t going to help you reduce stress if you only do it once a week, and a coloring book sitting on your bookshelf gathering dust isn’t going to magically cut your cortisol down.
Changing your mindset is often the hardest part of stress reduction, but possibly the most important. There are a lot of mindset issues that women deal with, but one of the most common mindset issues I see in the women I work with is poor body image.
Research shows that women with the lowest body image also have the highest levels of cortisol. (10) Any woman who has struggled with poor self-image and body dysmorphia knows what it feels like to have negative thoughts and emotions every time you catch your reflection in the mirror.
Building better body confidence is a challenging process, and it doesn’t happen overnight. But if you are struggling with negative thoughts about your body, constant dissatisfaction with your appearance, and poor mood that is worsened whenever you break your rigid diet and exercise routine, you may be sabotaging yourself by causing the very problems you feel negatively about, including weight gain, hair growth, and problematic skin!
Start by shifting your focus to all the things you are grateful for in your life. This could be something as simple as the fact that you have running water in your house, or as significant as having a loving partner or children that you adore.
Celebrate the success that you’ve had in your healthy eating and exercise goals, and don’t be so hard on yourself for the areas where you’ve fallen short. Everybody fails, so look at failure as a learning experience and opportunity for growth.
Stop following anyone on social media who makes you feel worse about your body or your life. Surround yourself with friends and role models who promote self-acceptance and self-love, regardless of what they look like right now.
Find people who inspire you to shift your focus to the positive things in your life, including what your body is capable of rather than what it looks like. Self-acceptance is a practice, and it requires committed effort to shift your mindset from one of self-loathing to self-love.
If You Need More Help …
There’s no way a single article will be enough for you to make a 180-degree turn in your life and start living totally stress-free. This will be a lifelong process that you need to commit to on a daily basis in order to see lasting changes in your hormonal health and wellbeing.
If you’ve already implemented the recommendations I’ve mentioned above and are still struggling, there are a few ways you can get additional help.
Chris’ 14Four program is a fantastic, holistic approach to a healthy diet and lifestyle that eliminates extremes and focuses not only on diet and exercise, but also stress and sleep. This is a great basic program for resetting your approach to a healthy, low-stress lifestyle.
If you are desperate to make major changes in the way you live your life, including the way you eat, the way you exercise, and the way you treat your body, and you want to experience the benefits of working one-on-one with a coach dedicated to your health and success, consider becoming one of my clients.
I love helping women just like you make evidence-based changes to their nutrition and fitness plans that not only help them reach their goals, but also eliminate the stress, confusion, and fear that comes with trying to do it alone.