Adolescence, Netflix: This stunning four-part limited series should be required viewing. Detailing the shockwaves to a family and a community of a murder case with a 13 year old suspect, the show is a critical examination of online radicalization, incel culture, and how we are raising (and failing) adolescent boys. As a mom who worries almost constantly about how to raise my son in the current online and cultural moment, it was a hard but important watch that I’ll be thinking about for years to come.
TCHO Chocolate - Recently discovered this certified B Corporation chocolate company who focus on innovating the chocolate industry, from developing better cacao beans to investing in farmers and roasters. The best part? The chocolate is darn good. I’ve been enjoying the Dark Duo as a perfect not-too-sweet after dinner treat.
Sunrise on the Reaping, by Suzanne Collins. I adore Suzanne Collins, an author who uses screenwriting approaches and fantastic three-act structures to tell extraordinarily timely stories about current sociopolitical climates. She’s back again with another addition to the Hunger Games universe, this time eviscerating the role of media and propaganda in perpetuating authoritarian regimes and obfuscating the realities of history. Secondary characters from the original trilogies feature prominently and the additions to their backstories are gutting. I devoured it, and can’t wait for the movie.
Welcome back to another semi-academic deep dive, the newsletter segment where I put my academic research training and scientific communications career to use translating a lot of scientific literature into something more digestible and (more importantly) applicable to your own life.In the past we’ve tackled the relationship between perfectionism and procrastination and burnout.
Today, we’re diving into polycystic ovary syndrome (PCOS), a hormonal condition I was diagnosed with over ten years ago. I have largely managed it successfully with holistic lifestyle interventions since then, but as I shared in a recent Sunday edition, have been experiencing a recurrence of symptoms following my experience of burnout this fall. I’ve been inspired to re-commit to what I know works, as well as dig into new research on what we know, what we don’t about how to manage this complex and varied condition.
Today’s issue has two main sections;
The topline summary of current research on PCOS: What is it, what causes it, and how is it treated? (spoiler alert: it’s all complicated).
My experience with PCOS, including diagnosis, symptoms, and how I currently treat and manage.
Let’s get into it!
Editor's note: this is the part where I call out that I’m not a medical professional. I’m a professional communicator with a background in research. I’m sharing empirically researched resources and references in a way that I hope is educational -a starting place to learn about something that could be useful. I am not making an individual recommendation for how you should handle a specific medical or health issue, and I highly recommend you speak with an actual care provider!
What is PCOS?
Polycystic ovarian syndrome (PCOS) is one of the most common hormonal disorders, affecting more than 116 million people worldwide. It impacts reproductive, metabolic and psychological health, with symptoms ranging from irregular periods and infertility, as well as hair loss, abnormal hair growth patterns, acne, insulin resistance and increased risk of type II diabetes and cardiovascular disease1.
Despite its prevalence, PCOS is under-researched, leading to frequent delays in diagnosis and dissatisfaction with treatment. It is typically diagnosed after symptoms negatively impact a patient’s quality of life. Current diagnostic criteria looks for at least two of the following markers2
Irregular or absent ovulation, causing missed or unpredictable periods
High Androgen levels, confirmed in one of two ways:
By blood tests that show elevated androgen (testosterone, etc) levels
Symptoms that indicate high levels of testosterone like hirsutism (hair growth on face, check, back and abdomen), hormonal acne (on the jawline, chin and upper neck), or female pattern hair loss.
Polycystic ovaries detected via ultrasound (includes an assessment of ovarian volume, number of visible follicles, and presence of ovarian cysts) OR testing anti-müllerian hormone (AMH) for patients without irregular cycles or hyperandrogegism
Other related symptoms can help confirm diagnosis and guide treatment3:
Cardiovascular disease profile including cholesterol (HDL, LDL and triglycerides)
Glycemic status (high blood glucose, insulin resistance)
Challenges with weight management, especially stubborn waist and abdominal fat
Sleep apnea
Pelvic pain
Moderate to severe symptoms of depression and anxiety
PCOS is a condition that can present differently in each person, causing challenges for diagnosis and standardization of treatment. As seen in the diagnostic criteria framework below, four patients with four different combinations of symptoms can and do qualify for the exact same diagnosis, and in many cases are given the same course of treatment or recommended interventions)4:
Unfer, V., et al., 2024
Recent research into the cause of this broad spectrum of symptoms within a diagnostic category has started to characterize two distinct subtypes based on groupings of diagnostic symptom patterns, and emerging research has confirmed these sub-groups via biological testing (genome-wide association studies) rather than expert opinion (traditional diagnostic criteria) 56:
A metabolic subtype - where the interplay between insulin resistance and increased ovarian androgen causes a subsequent development of ovarian cysts and menstrual dysfunction (types A, B, and C, above) - characterized by high BMI, high insulin and high blood glucose, and lower levels of LH and SHGB.
A reproductive subtype - where disruptions can’t be attributed to high androgens or insulin resistance, and could instead be related to dysregulation of secondary hormones specific to the female reproductive system - characterized by abnormal levels of luteinizing hormone (LH), follicle stimulating hormone (FSH), and sex hormone binding globulin (SHBG).
An indeterminate subtype, with presentations that do not definitively belong to either group.
Unfer, V., et al., 2024
While this is a semi-academic deep dive, I’d be remiss if I didn’t also cover and connect this research with some of the functional and integrative medicine classifications, which I find slightly easier to conceptualize and apply to my own experience. It’s also much more common around the internet —
if you google “types of PCOS” this is likely what you’ll find789
Insulin-resistant PCOS (maps almost directly to the metabolic subtype, above): IR PCOS occurs when the body's cells don’t respond well to insulin, which prompts the body to push out more to regulate blood sugar and digestive process. Over time, this can lead to increased production of androgens, disrupting menstrual cycles and causing symptoms like weight gain, acne, and excessive hair growth.
Adrenal PCOS: (largely maps to indeterminate subtype): A-PCOS occurs when the adrenal glands (which produces hormones like cortisol) overproduce androgens like DHEA-S (rather than testosterone). This type does not always have cysts, and can be challenging to diagnose.
Inflammatory PCOS (largely maps to reproductive subtype) - in I-PCOS, it’s thought that chronic inflammation disrupts hormone production and causes PCOS symptoms like irregular periods, weight gain, fatigue, gut issues, joint pain and acne. This type is often associated with other inflammatory and autoimmune conditions.
treatment & management:
Because of the broad spectrum of symptoms and challenges that come with PCOS, treatment is rarely one-size fits all and can largely depend on your specific symptoms: for many women, irregular menstrual cycles, infertility, hirsutism and weight gain are the most challenging, tend to be addressed first via medical interventions10:
Oral contraceptives and anti-androgen medications: birth control tends to be a first line treatment for PCOS to manage irregular cycles, acne and excessive hair growth.
Insulin sensitizers (eg. metformin): these medications can increase glucose absorption and improve sensitivity to insulin, which not only improves risk of type 2 diabetes and cardiovascular disease but also improve ovulation and regulate menstrual cycles.
Ovulation Inducers (e.g. clomid, letrozole): For those trying to conceive, ovulation inducers may act to regulate the disrupted reproductive hormones including LH and FSH.
Beyond medical intervention, lifestyle interventions are the primary treatment approach for women with PCOS, with a number of approaches demonstrating significant improvements on symptoms and quality of life11:
Diet: No single diet is “best” but a low glycemic index diet, and diets that generally follow The Dietary Approach to Stop Hypertension (DASH Diet - rich in fruit, veggies, whole grains, nuts, legumes, low-fat dairy) have been shown to improve insulin resistance, weight, BMI and hormonal profiles. Some more general findings:
low glycemic index diets are a particularly effective way to reduce waist circumference, BMI (which we know isn’t real, but can be a general marker of weight loss), and improve insulin sensitivity
higher protein meals reduce overall appetite and reduce blood sugar spikes (and subsequent insulin levels), resulting in weight loss over time, as well as improved depression scores.
improving fatty acid composition (increase unsaturated, decrease saturated fats), showing benefits for inflammatory markers, cholesterol, weight and insulin response.
Physical activity: Research backed guidelines recommend more than 150 minutes per week of moderate or more than 75 minutes per week of vigorous exercise, with a mix of strength training and aerobic exercise. Especially in combination with dietary interventions, exercise significantly improved weight, inflammation and hormone levels.
Sleep: Poor sleep and chronic stress can worsen hormonal imbalances and metabolic issues.
Supplements:
Vitamin D and Calcium: support insulin regulation and menstrual health
Inositols:Inositols, which act as secondary messengers for hormones including insulin, have a beneficial aspect on all aspects of PCOS, improving improve endocrine, metabolic and reproductive markers, normalizing cycle lengths, reducing androgen levels, lowering blood pressure, lipid and insulin levels, and increasing likelihood of pregnancy and effectiveness of fertility treatments1213
my experience with PCOS:
I was diagnosed with PCOS at 22 years old in 2014, after originally requesting an assessment for endometriosis due to debilitating pain with periods. My OB-GYN at the time recommended blood tests and a pelvic ultrasound, which showed low estrogen, elevated androgens and the classic polycystic ovaries. Taken with the hormonal pattern acne I had struggled with since I was a teenager, and the unexplainable weight gain around my abdomen despite the fact that I was currently training for a marathon, I was diagnosed with endometriosis and PCOS.
