Polycystic ovary syndrome (PCOS)

Women have likely had mild cases of PCOS since the dawn of humanity.

But given it’s unwanted symptoms, a useful question to ask is what evolutionary advantage would PCOS have given?

Estrogen, which tends to be elevated with PCOS, has protective roles in the body including increasing lean body mass, reducing abdominal fat, improving insulin resistance, lowering LDL to HDL cholesterol ratio and blood pressure, and maintaining the immune system. Lower estrogen is one of the reasons that these can worsen during menopause.

Women with PCOS tend to have elevated Testosterone, which is then converted into Estrogen. This may have provided our ancient female ancestors a survival advantage by limiting birth control and increasing physical strength.

From the list of estrogen’s roles, we can see the ‘reproductive system’ in the body is intimately linked with everything metabolic (blood pressure, weight, cholesterol etc.). Our hormones act as information systems in the body, with estrogen being a primary link to metabolic health.

And so the term polycystic ovary syndrome is somewhat misleading as it suggests the problem is only with the ovaries, and that you must have ‘cysts’ on your ovaries. When in fact, PCOS is a hormonal and metabolic condition, and exists as a sliding scale from mild to severe.

So why does PCOS tend to be associated with metabolic issues and obesity today?

Do you feel ‘hangry’ if you haven’t eaten? Blood sugar imbalances and insulin resistance tend to be associated with PCOS. In prehistoric times, this would have given women with PCOS an advantage as they were more able to store fat in times of plenty. The problem is that nowadays, we live permanently in times of plenty. Our high sugar, low quality diets are stored as body fat, often resulting in an increase in weight. This is exacerbated by the dramatic increase in the toxins in our environment, a sedentary lifestyle, and less diverse gut bacteria (our microbiome).

PCOS Effects

PCOS nowadays is common, probably affecting up to 25% of women. Thinning hair and acne, as well mood changes and depression, may be a sign of hormonal imbalances. Irregular or absent periods and metabolic dysfunction are symptoms of more overt PCOS.

The hormonal and reproductive effects of PCOS
The metabolic effects of PCOS

Optimising our Hormones

To optimise our hormones, it is useful to take a holistic Functional Medicine approach which considers everything that affects our hormonal health. This includes:

  • Diet and nutrients to support the body (supplements may include Inositol, B Vitamins, Vitamin D, Vitamin K, omega-3 fish oils)
  • Balance your blood sugar
  • Improve your gut health and support the gut microbiome
  • Reducing exposure to endocrine disrupting chemicals, particularly BPA
  • Healthy detox the body of toxins
  • Optimise the circadian rhythm, get natural light early in the morning. Intermittent fasting if tolerated
  • Manage stress
  • Quality Sleep and Quantity
  • Exercise mind and body
  • Passion and love for life

As a Functional Medicine practitioner, I’m qualified to support you in addressing all of these factors which may be contributing to your PCOS.

Diagnosis and Measuring our Hormones

PCOS is typically diagnosed when at least two of these present (note, that this means cysts on the ovaries may not be necessary for diagnosis) :

  • High androgens such as Testosterone
  • Absent ovulation or dysregulated cycles
  • Cysts on the ovaries from imaging

The DUTCH test provides a comprehensive overview of your sex and adrenal hormones, including Testosterone and it’s metabolites (these are important as the 5-alpha reductase metabolite is more androgenic), Estrogen and DHEA. If you would like to test your hormones, you can organise that through Fairfield Nutrition.

Gut Health and PCOS

A whistle-stop explanations of the impact of our gut health on PCOS is something like this:

  1. A typical high sugar diet, high in poor quality fats, and low in fibre creates an imbalance between ‘good’ and ‘bad’ bacteria.
  2. This imbalance affects the production of the protective mucus in our guts and the integrity of our gut lining is compromised. This is commonly known as ‘leaky gut’.
  3. Bacterial by-products (LPS) pass through the gut wall, initiating an inflammatory response. This inflammation contributes to insulin resistance which in turn drives Testosterone production in the ovaries.

Prebiotics and probiotics, as well as good sleep and managing stress etc., lead to more of the ‘good’ bacteria in the gut. These good bacteria produce short chain fatty acids that support the protective mucus layer and gut lining integrity. This results in a reduction in inflammation as fewer bacterial by-products cross the gut lining, which improves insulin sensitivity. This improvement in metabolic health tends supports a return to normal ovarian function and a lessening of PCOS symptoms.

Why are my iron levels still so low?

Iron deficiency is common, especially among women, vegetarians, and anyone who is hypo-thyroid. It can make you feel, tired, dizzy, moody, and cause head aches as the body doesn’t have enough iron to make haemoglobin, the protein in red blood cells that carries oxygen around the body.

This lack of healthy red blood cells is known as iron-deficiency anemia. Resolving this anemia is a crucial first step of any healing program as it robs cells of the oxygen they need to function.

Iron deficiency may explain persistent symptoms in between 30 to 50% of hypo-thyroid patients despite thyroid hormone therapy. Dr. Ruscio recommends testing for ferritin and getting ferritin levels above 100 in such cases.

Iron balance is critical with too much iron leading to oxidative damage, which may be part of chronic fatigue, liver disease, and brain function.

Iron as a supplement should only be taken following lab testing of iron levels in the body. When supplementing or when focusing on foods containing high levels of iron, some people find their levels remain stubbornly low. What’s going on?

What can you do?

If you suspect your have iron-deficiency anaemia, the first step is to talk to your doctor about testing to get confirmation. Excess iron can cause serious health conditions and low levels of iron are never something you should assume without testing.

Improving your iron absorption, and gut health, should be thought of as an important step to increasing iron absorption. Here are some things that can be done:

Inflammation and the gut?

Low grade inflammation is associated with all chronic disease. It can have a wide variety of causes, such as infections, injury, poor diet or toxins, even stress! But one of the most common areas where inflammation starts is in the gut.

When inflammatory cytokines are high (during infection or injury), the liver releases a regulatory molecule (hepcidin) which blocks the absorption of iron. In other words, inflammation blocks the absorption of iron from the gut.

You can read about how to reduce inflammation in our gut here. Inflammation in the small intestine in particular, often found with small intestine bacterial overgrowth (SIBO), is associated with poor absorption by the body of nutrients such as B12, iron, and zinc.

And so we need to consider inflammation of the gut when reflecting on why iron supplementation may not be raising iron levels in the body. This focus on the underlying systems of the body is a cornerstone of what is know as Functional Medicine.

Low Stomach Acid

Low stomach acid (HCl) is an important causative factor of anemia due to iron deficiency. Gastric HCl is important for nonheme iron absorption (non-meat iron sources) as this requires an acidic environment which helps the liberation of iron from food. In this article you can find out how to get an idea of your stomach acid levels with an east to do, at home, test.


Phytate is found in foods like whole grains, cereals, soy, nuts and legumes. It binds to minerals such as iron and zinc, preventing their absorption.

While eating some phytates is fine, many of us are eating more than the recommended amount, even those eating a Paleo diet containing a moderate amount of nuts.

But the research has shown eating even a small amount of phytate, at the same time as the source of iron, can decrease iron absorption. This inhibitory effect increases as the quantity of phytates increases. This is what is called a dose dependent effect. This effect can be counteracted by eating a source of Vitamin C at the same time.

Pair iron rich foods with Vitamin C

Iron from animal products, known as heme iron is the most easily absorbed by the body. But all is not lost if you are a vegetarian. Eating a source of Vitamin C along with plant base sources of non-heme iron helps absorption.

Foods high in vitamin C include citrus fruits, dark green leafy vegetables, bell peppers, melons and strawberries. In one study, 100mg of Vitamin C taken with food, increased absorption.

Iron and our Microbiome

Probiotics appear to increase the iron absorbing capability of the gut.

In particularly, a 2019 systematic review of the research found that the probiotic Lactobacillus plantarum 299v significantly increased iron absorption in humans.

Luckily for us, there are several commercially available probiotics containing this strain such as this one (affiliate link).

While we have discovered that some strains of probiotics increase iron absorption, other research is showing that other strains block absorption. And so to have optimal iron absorption from the gut, a balanced ecosystem of bacteria is needed. This means a healthy gut and microbiome!


DUTCH Hormonal Testing for Adrenal Fatigue and Hormonal Imbalances

DUTCH test for advanced hormonal testing and adrenal fatigue