The conventional medical treatment for PCOS includes anti-diabetic medications, such as metformin, aldosterone antagonists like spironolactone, and oral contraceptives. Nutrition can also address PCOS, making a significant difference in the course and severity of the condition. However, since no two PCOS cases are the same, it follows that no single diet will address all PCOS cases. Read on to learn about the nutritional strategies that can aid PCOS healing and which one may be right for you based on your unique physiology.
Do you have PCOS? Fine-tuning your diet may help your symptoms. Check out this article from nutritionist Lindsay Christensen for nine dietary strategies beneficial for PCOS. #nutrition #optimalhealth #wellness
What Is PCOS?
PCOS is a common but complex endocrine disorder that affects women of reproductive age. (2) It ties into multiple body systems, including the ovaries, adrenal glands, gut, and brain. Doctors rely on three main criteria to diagnose PCOS:
- Infrequent ovulation or anovulation, also known as “ovulatory dysfunction”
- Elevated androgen levels as indicated by a blood test, also known as “hyperandrogenism”
- Cysts on ovaries as indicated by transvaginal ultrasound, also known as “polycystic ovarian morphology”
A woman must fulfill at least two of the three criteria to receive a diagnosis of PCOS.
The most common symptoms of PCOS include:
- Irregular or missing periods
- Abnormal hair growth
- Male-pattern hair loss
- Blood sugar issues
- Weight gain or weight loss resistance
Women may present with the complete “conventional” PCOS symptom picture or with just a few of these symptoms. Importantly, as our understanding of PCOS evolves, we are coming to understand that PCOS occurs on a spectrum and that the three main criteria used to diagnose PCOS may not apply to all women with a PCOS-like clinical picture.
Underlying Mechanisms in PCOS
To understand how nutrition can improve PCOS, it helps to first understand some of the underlying mechanisms driving this condition. PCOS tends to be characterized by seven key features:
- Insulin resistance
- Gut dysfunction
- Chronic inflammation
- Hormonal imbalances
- Chronic stress
- Exposure to environmental toxins
Each of these mechanisms can be addressed, at least in part, by nutrition. Let’s discuss each of these mechanisms in turn and then dive into a discussion of how nutrition can help.
Insulin resistance is a condition in which cells in the muscle, fat, and liver do not respond appropriately to the hormone insulin. Insulin shuttles glucose from the blood into cells, allowing it to be utilized for energy production; when cells are unresponsive to insulin, glucose lingers in the blood, causing hyperglycemia. Hyperglycemia, in turn, triggers chronic inflammation and a host of adverse downstream health effects. Approximately 50 percent of women with PCOS present with varying degrees of insulin resistance. (3) Interestingly, insulin resistance can occur in overweight, normal weight, and lean women with PCOS; it does not appear to discriminate based on excess adiposity. (4, 5)
Correcting insulin resistance is an essential first step in the management of PCOS because high insulin levels directly contribute to hyperandrogenism by increasing the activity of enzymes in the ovaries that produce androgens such as testosterone. (6) In other words, you must correct the underlying hyperinsulinemia to correct excessive androgen levels.
Metformin is an insulin-sensitizing drug commonly used for the treatment of type 2 diabetes that has also been incorporated into the conventional treatment model for PCOS. While metformin is a relatively safe and effective drug, it can deplete vitamin B12 levels over time and is thus not without side effects. Fortunately, nutrition can be a powerful tool (and, arguably, should be the first tool used!) for correcting insulin resistance in PCOS because it directly impacts blood glucose regulation. I will discuss nutritional interventions that specifically address blood sugar dysregulation in more detail shortly.
Please note that insulin resistance is not a problem in all women with PCOS. While high insulin often drives the excessive production of testosterone in PCOS, it is not the exclusive cause of high testosterone. The hypothalamic–pituitary–adrenal (HPA) axis, which is the body’s stress-response system, can also stimulate the production of androgens, including dehydroepiandrosterone sulfate (DHEA-S) and androstenedione, independently of insulin. Androstenedione can, subsequently, be converted into testosterone and contribute to hyperandrogenism. This phenomenon is referred to as “adrenal PCOS” in the Functional Medicine community.
In the adrenal PCOS scenario, women can present with symptoms of PCOS even if they are perfectly insulin-sensitive. Women with the adrenal PCOS phenotype may need to focus on eating more carbohydrates, not less (more on this shortly), and may also need to spend more time addressing stress management to achieve relief from PCOS.
A growing body of research suggests that the gut microbiota may play an important role in PCOS by influencing key features of the syndrome, including insulin resistance, hyperandrogenism, and chronic inflammation.
Disrupted intestinal short-chain fatty acid (SCFA) production may also mediate the relationship between the gut and PCOS. SCFAs are metabolites generated by gut bacteria when they break down dietary fibers from foods consumed in the diet. While certain SCFAs, such as butyrate, offer anti-inflammatory health benefits, other SCFAs have less desirable effects. Abnormal SCFA metabolism in PCOS may lead to a preponderance of SCFAs that stimulate appetite and “energy harvest” from the diet, increasing the amount of energy (particularly in the form of carbohydrate) that the gut absorbs from foods. This phenomenon may, in turn, contribute to higher blood sugar levels, insulin resistance, and body fat accumulation. (7) Correcting disrupted gut microbiota may improve abnormal SCFA metabolism and the downstream metabolic consequences in PCOS.
Gut microbiota disruption also increases intestinal permeability (aka “leaky gut”) and levels of lipopolysaccharide, a pro-inflammatory metabolite made by Gram-negative gut bacteria. (8) These factors precipitate chronic inflammation, which is a crucial underlying factor in the pathophysiology of PCOS.
Chronic inflammation is a common thread that links together the various characteristics and symptoms of PCOS. Chronic inflammation:
- Impairs insulin sensitivity and blood sugar control
- Disrupts the gut microbiome
- Impairs the HPA axis
- Disrupts hormonal balance
The sources of chronic inflammation in PCOS have not been fully elucidated but may originate in the gut, adipose tissue, and ovaries. (10, 11) Various dietary factors can contribute to chronic inflammation, so removing common dietary inflammatory triggers can significantly improve multiple aspects of PCOS.
PCOS is characterized by an array of hormonal imbalances. Androgen excess, which can manifest as excess testosterone and DHEA, is a key feature of PCOS. Androgens can be produced from estrogen when insulin is high (as is the case in insulin resistance). However, excess androgens can also originate from the adrenal glands in a specific subset of women with PCOS; this presentation is adrenal PCOS. (12) Adrenal PCOS is driven by an abnormal stress response.
Women with PCOS often have excess estrogen as well as elevated androgens. (13) This can cause an androgen excess and an “estrogen dominance” picture. Here, too, nutrition can offer powerful benefits for decreasing androgen excess and normalizing estrogen levels.
Chronic stress can both trigger the onset of and exacerbate existing PCOS. Research indicates that women with PCOS demonstrate dysfunctional stress responses (aka HPA axis dysfunction) that may be both a cause and an effect of PCOS. (14) Women who tend to experience PCOS-like symptoms only when under stress may have the “adrenal PCOS” phenotype, as discussed earlier. For more information on how to use nutrition to support a healthy HPA axis and stress response, check out my article on this specific topic.
While fine-tuning your lifestyle and developing a stress-management routine is essential for reducing stress, diet can play an influential role in helping the body manage stress and can thus influence PCOS through this route, as well.
Exposure to Environmental Toxins
Emerging research indicates that environmental toxins may play a significant role in the pathogenesis of PCOS. (15) Bisphenol A (BPA) and phthalates are plasticizers found in various consumer products and, inside the body, exert hormone-disrupting effects. Pesticides commonly used in agriculture also disrupt hormonal balance, and women with PCOS have been found to harbor higher levels of pesticide residues in their bodies than women without PCOS. (16) Research indicates that these environmental toxins may play a role in PCOS development by mimicking hormones and disrupting metabolic homeostasis.
There appears to be a critical window early in life in which exposure to these environmental toxins leads to epigenetic changes that contribute to PCOS later in life. Whether these same toxins can contribute to PCOS with exposure during adulthood remains to be seen; however, I suspect that avoiding these toxins, on the whole, will be beneficial for women with PCOS since these toxins can also disrupt the gut microbiome and promote inflammation, driving other mechanisms involved in PCOS. (17)
Interestingly, PCOS appears to be common in elite female athletes; in fact, the elevated androgen levels in these women may contribute to their athletic drive and performance! Whether PCOS is a cause or an effect of ongoing, excessive physical activity is not yet clear. (18) However, in my clinical experience, I have worked with women with a PCOS diagnosis who are not athletes but maintain a high level of physical activity and have noticed an important relationship between overtraining and exacerbation of PCOS-like symptoms.
From a scientific perspective, it is possible that overtraining, or exercising to a degree that exceeds your body’s ability to recover, may contribute to a PCOS-like clinical picture by driving up cortisol and decreasing female sex hormones. Failing to eat sufficient calories in combination with overexercising may provoke even more problems with hormonal balance. In women, this phenomenon is referred to as the “female athlete triad.” While the female athlete triad is classically associated with underweight and amenorrhea, our understanding of the condition is evolving; more and more, it appears possible that PCOS may emerge from this constellation of excessive exercise and restrictive dietary behaviors.
Nine PCOS Nutrition Interventions To Ease Symptoms and Improve Your Health
To ease symptoms of PCOS and improve health, it is crucial to address the root causes of PCOS. Nutrition can address multiple underlying causes of PCOS, including blood sugar dysregulation, gut dysfunction, chronic inflammation, and hormonal imbalances. Fine-tuning your diet can also help you avoid pervasive environmental toxins linked to hormone disruption and improve your ability to manage stress.
1. Eat an Anti-Inflammatory, Paleo Template Diet
An anti-inflammatory, Paleo template diet is an excellent place for most women with PCOS to start when it comes to modifying their diet.
A Paleo template diet removes refined carbohydrates and industrial seed oils, which are common dietary inflammatory triggers that are known to provoke chronic inflammation, and may thus exacerbate PCOS symptoms.
Refined carbohydrates provoke swings in blood sugar and disruptions in the gut microbiota that contribute to chronic inflammation. (19) Instead, women with PCOS should focus on eating whole food-based, nutrient-dense carbohydrates such as sweet potatoes, winter squash, whole fruit, and properly prepared grains and legumes, if tolerated. The soluble fiber found in cellular carbohydrates also favorably impacts blood sugar control and can help correct the dysglycemia associated with PCOS.
The consumption of industrial seed oils, such as canola, corn, cottonseed, and soybean oils, exacerbates inflammation by disrupting the body’s omega-6/omega-3 fatty acid ratio and by exposing the body to oxidized lipid byproducts created during oil processing. You can learn more about the inflammatory effects of industrial seed oils in Chris’s article “How Industrial Seed Oils Are Making Us Sick.” Many women with PCOS will notice a significant improvement in their symptoms simply by removing these pro-inflammatory, processed oils.
Instead of consuming industrial seed oils, choose healthy fats such as:
- Extra virgin olive oil
- Avocado oil
- Coconut oil
- Nuts and seeds
- Fatty cold-water fish
These fats offer anti-inflammatory properties and aid hormonal balance. (20) Keep in mind that while avocado oil is a great option, it is important to vet out a high-quality product since recent research indicates that many avocado oil brands are adulterated with industrial seed oils. (21) Whole avocados may offer added health benefits for women with PCOS by providing a compound called avocation B that has been found to improve insulin sensitivity. (22)
Last but not least, don’t forget to include plenty of non-starchy vegetables in your diet. These foods contain fiber, regulating gut health and hormone elimination, and phytonutrients with anti-inflammatory and insulin-sensitizing properties.
2. Incorporate Healing Foods and Nutrients for PCOS
Various foods and nutrients can help correct underlying mechanisms involved in PCOS and improve PCOS symptoms. These foods and nutrients include:
- Citrus fruits
Magnesium is a cofactor for over 300 enzymatic processes in the body. It plays an essential role in hormone metabolism and helps to maintain hormonal balance. Research suggests that maintaining optimal magnesium levels may improve insulin resistance in PCOS. (25) Magnesium also supports healthy HPA axis function. (26) Good food sources of magnesium include:
- Dark leafy greens
- Pumpkin seeds
Research indicates that zinc insufficiency may play a role in the metabolic dysfunction characteristic of PCOS. (27) Good food sources of zinc include:
- Grass-fed beef and bison
- Oysters and other shellfish
Fatty, Cold-Water Fish
Fatty, cold-water fish are rich in the omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), which may improve blood sugar control and dyslipidemia in women with PCOS. (28) To remember which types of fatty, cold-water fish are richest in omega-3 fatty acids and lowest in pollutants such as mercury, refer to the SMASH acronym, which stands for “salmon, mackerel, anchovies, sardines, and herring/halibut.”
Cruciferous vegetables such as broccoli, Brussels sprouts, cauliflower, kale, radishes, and rutabaga are rich in phytochemicals that support healthy hormone metabolism. One such phytochemical, diindolylmethane, beneficially modulates estrogen metabolism, promoting the production of “good” estrogens and minimizing the production of “bad” estrogens. Increasing cruciferous vegetable intake may be particularly beneficial for women with PCOS who have estrogen dominance.
Green tea may decrease fasting insulin and testosterone in overweight women with PCOS, improving two critical hormonal imbalances associated with the condition. (29) Green tea also beneficially modulates the HPA axis, and may thus help manage adrenal PCOS. (30)
Blood Sugar-Regulating Foods
If insulin resistance is a part of your PCOS presentation, then incorporating insulin-sensitizing foods may help. Dark blue and purple berries, such as blueberries and blackberries, are rich in phytonutrients called anthocyanins that support insulin sensitivity. (31) Extra virgin olive oil also contains phytochemicals with insulin-sensitizing effects, while the acetic acid in balsamic vinegar enhances muscle glucose uptake, reducing circulating levels of glucose. (32, 33)
Fermented Foods and Prebiotic Foods
Fermented foods contain probiotic microorganisms that may improve gut health, addressing the gut microbiota component of PCOS. Prebiotic fibers, which are abundant in artichokes, sunchokes, green banana flour, onions, and garlic, among many other plant foods, feed beneficial gut bacteria and may support the restoration of healthy gut microbiota in PCOS. (34, 35)
3. Consider a Ketogenic Diet
Women with PCOS who are overweight and insulin-resistant may do well with a ketogenic diet. In women with PCOS, a ketogenic diet has been found to improve numerous markers of metabolic health, including decreasing fasting blood glucose, insulin, and the homeostatic model assessment for insulin resistance (a measure of glucose tolerance), and improve features of hormonal balance such as the luteinizing hormone/follicle-stimulating hormone ratio, testosterone, DHEA-S, estradiol, progesterone, and sex-hormone-binding-globulin. (36)
Please note that a ketogenic diet is not appropriate for all women with PCOS, particularly those who are a normal weight or lean and are struggling with PCOS symptoms related to chronic stress, under-eating, and overtraining.
4. Correct Insufficient Calorie Intake and Address Disordered Eating Behaviors
While overnutrition, defined as an excessive intake of calories and macronutrients, can contribute to PCOS in some cases, insufficient calorie intake can trigger or exacerbate PCOS in some instances. Inadequate calorie intake can trigger a physiological stress response, driving cortisol levels up and dysregulating sex hormones such as estrogen, progesterone, and testosterone.
In my clinical experience, I’ve found that disordered eating patterns (namely, an insufficient calorie intake) can also lead to a PCOS-like symptom picture. This observation is corroborated by a cross-sectional study indicating that women with PCOS who demonstrate a more anxious phenotype have a significantly increased risk of disordered eating behavior, as indicated by the Eating Disorder Examination Questionnaire. (37) Whether disordered eating behavior is a cause or an effect of PCOS remains to be elucidated by the scientific literature; however, in my experience, addressing disordered eating behaviors can have profoundly beneficial effects on PCOS symptoms.
If you are very physically active, you must make sure you eat enough calories to fuel your activity level. A nutritionist can help you determine how to best eat to support your physical activity level and minimize PCOS symptoms.
5. Correct Insufficient Carb Intake
On the flip side of keto, an insufficient carb intake can exacerbate PCOS symptoms in some women, particularly those with “adrenal PCOS.” For women with adrenal PCOS who need more carbs, a range of 20 to 40 percent of total calories as carbohydrate often works well.
6. Optimize Protein Intake
Optimizing protein intake helps to promote healthy blood sugar control. Dietary protein attenuates postprandial blood sugar fluctuations, helping to regulate insulin levels, and aids satiety and appetite control. (38) A range of 20 to 25 percent of total calories from protein works well to support blood sugar control, appetite control, and satiety in women with PCOS. Focus on eating highly bioavailable protein such as:
- Grass-fed beef
- Wild game
- Fatty cold-water fish
7. Try Going Dairy-Free
Dairy products naturally contain some hormones and hormone-like molecules, including insulin-like growth factor 1 (IGF-1). IGF-1 signaling is implicated in ovarian hyperandrogenism, and eating dairy products can worsen PCOS symptoms in some women. (39)
8. Try Seed Cycling
Seed cycling is a nutritional strategy designed to support female hormonal balance throughout the menstrual cycle. It involves eating four different types of seeds—pumpkin, flax, sesame, and sunflower seeds—at different points throughout a woman’s cycle. During phase 1 of the cycle, which lasts two weeks, women are instructed to eat a tablespoon of flax and a tablespoon of pumpkin seeds each day. During phase 2 of the cycle, women are advised to eat sunflower and sesame seeds daily.
Seed cycling may sound good in theory, but does it really work? Based on my research and clinical experience, seed cycling could, theoretically, enhance estrogen or progesterone production in the body. For example, flax seeds have some estrogen-modulating properties and have been found to improve metabolic health markers in women with PCOS. (40) In cell culture studies, pumpkin seeds have been shown to contain phytochemicals called lignans that modulate estrogen receptor activity. (41)
While seed cycling is worth trying, I do not necessarily think it is enough on its own to promote hormonal balance in PCOS.
9. Limit Exposure to Toxins in Food and Water
Last but not least, an important component of optimizing nutrition for PCOS healing is avoiding food-borne environmental toxins. Plastic food storage containers contain endocrine-disrupting plasticizers such as BPA and phthalates; to minimize your exposure to these toxins, I recommend that you use glass or stainless steel food storage containers at home instead. (42)
To minimize exposure to endocrine-disrupting pesticides, try to buy organic produce as much as your budget allows. You can refer to the EWG’s Dirty Dozen and Clean 15 lists to learn which fruits and vegetables you should prioritize purchasing organic. I also recommend using a filter for your drinking and cooking water because endocrine disruptors are common in tap water. (43)
Nutrition is truly a root-cause tool for addressing the underlying mechanisms and improving symptoms of PCOS. With an understanding that no two cases of PCOS are the same, it may require some self-experimentation to determine the optimal nutritional approach that will alleviate your PCOS symptoms and improve your health. However, it is well worth the effort! If you feel that you could use personalized, one-on-one help with managing your PCOS with a comprehensive nutrition and Functional Medicine approach, consider working with us at the California Center for Functional Medicine.