PCOS and Insulin Resistance: Part 5 How to treat PCOS?
The current conventional PCOS treatment focuses on managing the patient’s individual signs and symptoms. The specific treatment prescribed will include medications and/or lifestyle modifications. This is called disease management. At any one time a patient might be on 2 or more medications (Figure 1) and trying real hard to “eat less and move more” in order to see metabolic and reproductive improvements.
Figure 1 Polypharmacy
My goal, whether through IDM (Intensive Dietary Management), or by writing more posts about PCOS and Insulin Resistance, is to, hopefully, help people understand the pathophysiology of this syndrome, so that the treatment plan makes sense.
As I mentioned above, the conventional treatment focuses on treating the symptoms. If a woman is diagnosed with PCOS and she presents with irregular menses, acne, infertility, hirsutism (hair growth), and obesity, each of these symptoms will be addressed individually by prescribing one (or more) medication(s) for each … MAJOR problem. All medications have potential adverse effects.
One of the primary treatments for PCOS, is the birth control pill. The combined pill (estrogen and progesterone) is effective in lowering androgen (male hormone) levels and normalizing estrogen (female hormone) which will help with acne, abnormal hair growth and irregular menses. You can’t take the birth control pill and expect to get pregnant, so this won’t work for those trying to conceive. The pill, unfortunately, does not come without its own side effects. The 10 most common ones listed here.
Some effective acne medications adversely affect the liver and are harmful during pregnancy and lactation (birth control pill recommended). So here, again, you can’t have clear skin and also get pregnant. Clomid, a commonly used fertility drug, stimulates ovulation (which may help some conceive), but poses the risk of a very serious condition known as OHSS (ovarian hyperstimulation syndrome). If you don’t become pregnant with clomid alone, your doctor may recommend metformin, another drug, this time a diabetic drug, to improve insulin sensitivity (this is what happened in my case). Metformin comes with its own slew of side-effects (gastro-intestinal discomfort being only one of them).
For hair growth (Figure 2), there’s a drug that may also cause birth defects, so some form of very effective birth control must be taken (so, again, no baby if you want to have smooth, non-hairy skin). Besides shaving (yes, women with PCOS may have to shave their facial hair daily) there are very $$$ methods of permanent hair removal (electrolysis, laser, intense light pulsing … yup, been there too).
Figure 2 Hirsutism
To address obesity, some doctors may recommend weight-loss drugs. Xenical is a weight-loss aid with horrid and embarrassing side-effects. Metformin has been shown to have some minimal effects on weight. Many doctors just tell women to lose weight. Here our good old friend CICO, calories in and calories out, might be invited back to the party. Most of the time, women are told by their doctor(s) to just “eat less and move more”. This might be an issue for women with PCOS, and many will probably tell you, they have tried this, real hard, but it didn’t seem to significantly help. The self-help guides and books I have read on PCOS (many of them do mention Insulin Resistance as a significant factor in PCOS), while trying to help people with this condition, also encourage the idea of eating less (smaller meals, more times per day) and moving more (any form of exercise).
Although I have no problems with exercise, per se, in fact, I, too, find it important (surprise, surprise), but I prescribe it for a different reason entirely (not for weight loss, I mean). The “eat small meals, many times a day” approach, on the other hand, I am completely against.
When I was diagnosed with PCOS, I was never referred to a nutritionist or dietitian, and my doctor for sure did not take the time (nor did he have the time) to go over a proper dietary approach with me. When diet is addressed, patients likely are told to partake in a low-calorie, low-fat diet to help lose weight (i.e. just starve). Luckily, for me, diet was all that I knew, so I had a lot to work with.
At any one time, women with PCOS may be on 2 or more drugs, for years at a time, and none of these actually treat PCOS, nor do they prevent the incidence of Type 2 Diabetes, Heart Disease and all the other Metabolic Syndrome conditions that women with PCOS have been shown to be at an increased risk of (Figure 4).
Figure 4 Prevalence of different elements of metabolic syndrome in women with PCOS
If I am going to offer constructive criticism, then I must offer alternatives. I am a big believer in complimentary medicine. As a Naturopathic Doctor, I work best in a complimentary medicine setting (alongside Medical Doctors and other practitioners). This means combining some meds (to help manage symptoms, if and when necessary) and the proper dietary and other lifestyle approaches. We are best served taking advantage of the advances in Medical Science (such as proper lab tests and treatments), while not forgetting that the body has an innate ability to heal thyself (this is Naturopathic lingo).
How SHOULD PCOS be treated (according to me)?
Forty to 70% of women with PCOS may be able to address all the above signs and symptoms without having to take any medications. How? By following a proper dietary and lifestyle approach that addresses hyperinsulinemia and Insulin Resistance. What if this same diet could also help to prevent Type 2 Diabetes, Fatty Liver, Sleep Apnea, Obesity and Heart Disease, which a great majority of these women are also afflicted with (Figure 4)?
What is this diet I speak so highly of? For those of you not familiar with the IDM (Intensive Dietary Management) Program, our goal is to address Metabolic Syndrome caused by Hyperinsulinemia and Insulin Resistance by prescribing a Low-Carb (higher Fat) diet and Intermittent Fasting.
Figure 5 LCHF (Low Carb High Fat) Diet