Understanding PCOS and Fertility
6 minutes
There are several reasons a female might have irregular menstrual cycles. One such reason was discussed in a previous blog post about hypothalamic amenorrhea. However, a much more prevalent and studied reason is actually something that is estimated to affect 8 to 13% of women of reproductive age, and potentially higher given many go undiagnosed. Polycystic Ovary Syndrome (PCOS) is a hormonal disorder that affects many women but is often not addressed until they are ready to conceive and encounter issues such as irregular menstruation, difficulty becoming pregnant, tracking cycles, or experiencing miscarriages. Upon learning about her condition, a woman often feels frustrated and misunderstood, experiencing a mix of relief and fear after years of not understanding why her body reacted differently compared to other women.
A common sentiment when someone is first diagnosed goes something like this: "I'd been struggling with irregular periods and unexplained weight gain for years and when my doctor finally diagnosed me with PCOS, it was a mix of relief and worry. I finally had an explanation, but I was scared about what it meant for my future, especially my dreams of becoming a mother."
The Impact of PCOS
PCOS is characterized by a combination of symptoms, one of the main ones being irregular menstrual cycles or even amenorrhea (a complete absence of menstrual cycles). This irregularity might become masked with a one-size-fits-all approach of being put on birth control without further addressing underlying causes. Other markers of PCOS include elevated levels of male hormones which may lead women to experience excess hair growth, acne, weight gain (especially around the midsection), deepening of the voice, enlargement of the clitoris, and polycystic ovaries. These ovaries, when viewed on an ultrasound, typically appear larger than normal with many small follicles, often described as looking like a "string of pearls." Sometimes the latter can be misdiagnosed as cysts, which is why working with an informed doctor is important.
These symptoms, which don’t affect every person with PCOS uniformly, typically begin to appear during puberty or in someone's early 20s. Some women may believe they were just born with more body hair and take care of it through waxing or laser. Often the thing PCOS patients are most frustrated by before learning about their condition is feeling that they are gaining weight despite their best efforts through diet and exercise. Without getting properly diagnosed, this can lead to a pattern of restriction and binging, exacerbating their weight issues and potentially turning into an eating disorder.
A woman who experiences anovulation, which is the absence of ovulation, or finds it really challenging to track due to its inconsistency will struggle to conceive. The hormonal imbalance, particularly the elevated levels of androgens (“male” sex hormones like testosterone) and insulin resistance, disrupts the normal ovulation process. Studies highlight the significant impact of PCOS on fertility:
Prevalence of Infertility: Research indicates that approximately 70% to 80% of women with PCOS experience infertility due to anovulation or irregular ovulation cycles.
Miscarriage Rates: Women with PCOS also have a higher risk of miscarriage, estimated at around 30% to 50% compared to 10% to 15% in the general population.
Need for Treatment: More women with PCOS used fertility treatment – 38% compared to 13% of women without PCOS.
Causes of PCOS
The exact cause of PCOS remains a mystery, but factors such as genetic predisposition, insulin resistance, and inflammation all play a role. Given there is no easy treatment solution, it often is difficult to manage. Someone with PCOS and trying to conceive who isn’t ready to go down the assisted reproduction route will need to resort to either lifestyle changes, medication, or both.
All I’ve ever been told is I need to change my Lifestyle - Ugh
Going to the doctor and being told that you need to lose weight to conceive is extremely frustrating for someone who has likely battled with their weight much of their life. For many women with PCOS, being in a bigger body has likely been a source of discomfort and frustration, especially when faced with insensitive comments or dismissive attitudes from healthcare providers. One of the most common things I hear from a client who has PCOS is, "Doctors take one look at me and blame all my health issues on my weight, without really listening to my concerns.” This kind of messaging is disheartening and hurtful and leads many women to hesitate to seek help when it comes to their fertility, and as you are likely aware, fertility does not age well.
What do Lifestyle Changes entail?
There has been a significant rise in research to answer this question when it comes to PCOS and fertility in particular. Based on various research studies, any type of balanced diet has been shown to help manage PCOS. However, the two standouts seem to be both low-carbohydrate and high-protein diets since they help improve insulin sensitivity and reduce androgen levels, as well as a more specific Mediterranean diet. The Mediterranean diet emphasizes whole, unprocessed foods, including a high intake of fruits, vegetables, whole grains, legumes, nuts, seeds, and healthy fats like olive oil. It includes moderate consumption of fish and poultry, limited intake of red meat and sweets, and even a little red wine for those inclined. Some studies have also demonstrated that the high content of antioxidants and omega-3 fatty acids from sources like fish and olive oil helps in reducing inflammation and improving fertility outcomes.
In terms of exercise, all exercise is helpful for managing PCOS. However, studies have demonstrated that a combination of cardiovascular and strength training is superior to just one type. Strength training in particular helps reduce androgen levels. Additionally, higher-intensity workouts, such as High-Intensity Interval Training (HIIT), have demonstrated improvements in insulin resistance and body composition. As a perinatal personal trainer that works with clients seeking lifestyle choices to manage PCOS, I can anecdotally affirm that a combination of strength and cardio as well as some higher-intensity workouts has led to quicker results for ovulation to either return or for menstruation to be more routine and predictable.
Although research on effective strategies is helpful, if someone is coming to me wanting to change their lifestyle, the absolute best approach is one they will feel most comfortable with and that resonates with them. A diet or exercise regime that they dread, or dislike is a setup for inconsistency and then a cycle of blame and feeling they “failed.” Put another way, lifestyle changes are not a one-size-fits-all treatment protocol of ‘diet and exercise,’ it’s taking a balanced approach to nutrition and exercise that you personally feel fits your current life as opposed to trying to create a completely new life. It’s also really important to recognize when you need help. For individuals with a history of disordered eating or emotional eating, addressing the mental health aspects is important to ensure these lifestyle changes are sustainable.
Assisted Reproduction Options
When lifestyle changes are not sufficient or timing is of the essence, turning to assisted reproduction is another option that can be used along with your own efforts to change. There are several ways to go about this. Medications like Clomiphene Citrate, Letrozole, and Metformin are often used to induce ovulation and improve insulin sensitivity. With the use of those medications, a couple can still try to conceive more naturally with timed intercourse. For more advanced treatments, a combination of medication and intrauterine insemination (IUI) or in vitro fertilization (IVF) may be necessary.
Newer Medications – The Ozempics
It would be remiss of me to write this without mentioning the new GLP-1 drugs (i.e., Ozempic, Wegovy, Zepbound, and Mounjaro) that were originally developed to treat diabetes but have recently gained widespread popularity for weight loss. There have been many anecdotes that people taking these semaglutide or tirzepatide medications have been surprised with pregnancy. Given that the drugs also act to regulate insulin, it makes sense that they may help manage PCOS and lead to an increase in ovulatory normality. Further research is needed to fully understand the correlations, but it might be an important consideration for individuals dealing with PCOS and infertility. With that said, it’s important to note that it’s currently recommended to stop taking these medications at least two months before trying to conceive, as there is limited information on their safety during pregnancy.
Conclusion
For women struggling with PCOS and fertility, it can be daunting, especially if they have felt dismissed in the past. However, it is important to seek a healthcare provider who understands the nuances of the condition. Anyone who suspects they might have PCOS but hasn't been diagnosed should definitely seek evaluation, as early intervention can improve the chances of reducing fertility struggles in the future.
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