Poly Cystic Ovarian Syndome (PCOS) is a fertility condition that affects between 10 and 15 percent of women in the Western world.
All of these women suffer from at least some of the symptoms of PCOS: irregular menstrual cycles, weight gain, difficulty with weight loss, low libido, facial hair growth, balding, and, perhaps most popular of all, acne.
PCOS and acne are inextricably linked. Why? Because PCOS is caused by an underlying hormone imbalance. The very same underlying hormone imbalance causes acne. It is possible to have PCOS without acne, and possible to have this kind of acne without PCOS. But quite frequently they occur together.
Here in this post I explain the hormone imbalance that causes PCOS, and the ways in which it also causes acne.
Also, and importantly: after figuring out how to overcome my own PCOS and acne, I wrote a manual on overcoming PCOS. It’s PCOS Unlocked: The Manual, and you can read all about it here.
PCOS and acne: the underlying hormone imbalance
Most medical professionals understand the hormone problem that underlies PCOS to be quite simple: elevated insulin levels cause the ovaries to produce excess testosterone, which throws a wrench in the menstrual cycle and causes irregularity, cysts on the ovaries, and infertility.
This does indeed happen to be the case for many women with PCOS. Testosterone is their biggest problem. In my PCOS manual, I call this “type I PCOS”.
Yet there are other types of PCOS.
Low female sex hormone levels are another cause of PCOS.
Why? Because–even though most medical professionals don’t understand this–PCOS is not just about high testosterone, but is rather about a fundamental imbalance between testosterone and the female sex hormones.
When estrogen and progesterone levels fall, they get out of fundamental balance with testosterone, which also throws a wrench in the menstrual cycle.
Estrogen and progesterone levels fall for any number of reasons, though by far the most popular reasons have to do with stress and with starvation.
The thing about the female body is that it is highly sensitive to any conditions that may impair it’s ability to healthfully bear children. If you imagine life millions of years ago back on the savannah, it would be quite common for natural disasters or tribal conflict to create stressful times that could hinder a healthy pregnancy. It would also be quite common to come into a period of famine, in which case pregnant women would not be able to get enough food to sustain their pregnancies.
In periods of stress and starvation, pregnant women die more easily.
In order to prevent this from happening, the female body shuts down hormone production when it detects the slightest bit of stress or starvation. Shutting down hormone production prevents the body from becoming pregnant, which would have saved an ancestral woman’s life in the long run.
Our bodies do the same thing.
If we count calories, resrict food intake, limit carbohydrates or fat too much, yo-yo diet, or excercise excessively, our sex hormone levels fall, and our estrogen and progesterone levels become too low both for a healthy menstrual cycle and for clear skin.
You can read more about the female body and psychological stress in this post: psychological stress and hypothalamaic amenorrhea, and more about the female body and starvation-type stress in this post: metabolic distress and hypothalamic amenorrhea.
There is yet one more popular hormone problem that causes PCOS. It’s what happens when DHEA-S levels rise.
Elevated levels of DHEA-S contribute to PCOS because DHEA-S is also an androgen, or male sex hormone.
DHEA-S and testosterone act very similarly in the female body. The primary difference is that testosterone is produced by the ovaries, and DHEA-S is produced by the adrenal glands.
DHEA-S levels rise in response to stress. Whenever you feel stressed out, your body has a choice to make: it can continue to direct it’s hormonal resources toward sex hormone production, or it can divert those resources toward stress hormone production.
This process is often called “pregnenolone steal.” The reason we call it a “steal” is that hormonal resources are literally stolen by the adrenal glands and used for sex hormone production.
Thus you end up with lower hormone levels (like estrogen, progesterone, and the pituitary signalling hormones LH and FSH), as well as elevated DHEA-S levels, which can cause testosterone-like symptoms in the body: PCOS, infertility, facial hair growth, and acne.
So in sum, there are several hormonal factors that may be at play in PCOS:
Testosterone levels may be too high largely due to insulinemia
Estrogen and/or progesterone levels may be too low due to psychological and physical stress
DHEA-S levels may be too high due to psychological stress
Causes of PCOS and causes of acne
So in a very brief, very simplified nutshell: PCOS is caused by and large by an imbalance between male sex hormones and female sex hormones. If testosterone or DHEA-S is elevated, PCOS may result. If estrogen or progesterone is low, PCOS may result. Any of these things can happen at the same time, and often do.
(For more on the details of how all this happens, check out the PCOS manual here.)
This hormone imbalance is also one of the primary causes of acne.
How hormones and acne work
There are three separate layers to the skin, and pores traverse these layers. In order to adequately protect your body and keep toxins on the outside, the outer layer of the skin has to be hydrated and strong.
Pores deliver oil to the out layers from the bottom up. In healthy skin, oil comes up through the pores and oozes onto the surface, lubricating the skin and making it look soft and glowy. Think of it like a well, or a hot spring, or an oil rig.
In acne-prone skin, debris from the surface clogs pores, bacteria clog pores, and oil coming up from the bottom clogs pores. Then all this oil oxidizes and bacteria go on a feeding frenzy – which makes the pores become infected and inflamed.
The problem for women with PCOS is that male sex hormones increase oil production.
Estrogen performs an opposite function, and helps sooth the skin.
When estrogen levels are low, and when oil production increases from elevated testosterone or DHEA-S, acne is often the result.
The kind of acne that usually accompanies PCOS is around the chin, the mouth, and the jaw. It can spread to other areas of the face and the body, particularly the shoulders, buttocks, and back of the thighs, because these are the areas where the skin has the most testosterone receptors. If you have acne in these places there is quite a decent chance that your hormones are at least a bit out of balance, PCOS or no.
For more on hormones and acne, check out this post: cystic acne and hormones: everything you need to know.
PCOS and acne: what to do about it
So what do you do about your acne and PCOS?
For one, tackling PCOS should be a priority.
You can do so by utilizing the manual for overcoming PCOS I’ve mentioned a few times that I’ve used with thousands of women, which you can read all about here.
You can also read some other posts I have on PCOS:
What is PCOS?
The PCOS Diet
5 Things I wish I knew when I was diagnosed with PCOS
PCOS and hypothalamic amenorrhea: What’s wrong with the contemporary understanding and how you can have both
You may also wish to consider tackling your acne from more than one angle. PCOS and underlying hormone problems are in all likelihood a significant factor in your acne, yet there are probably other factors at play. To that end you may wish to check out the posts:
The ultimate hormonal acne treatment plan
Acne: thinking beyond hormones
And, most of all, I highly recommend the remarkable acne program by my favorite thinker on the topic of acne, Seppo Puusa. I have learned so much of what I know about acne from Seppo. You can read all about his work, his program, and what he has to offer HERE.
And that’s it! Please let me know your thoughts, your problems, your experiences in the comments! I and everyone else in our community would be honored to learn through your life and wisdom 🙂
I was diagnosed with PCOS in 2009.
At the time, everything I knew about PCOS came from the flimsy little pamphlet my doctor handed to me after my ultrasound. Even after spending a few months scouring the web for more info on PCOS, I was still pretty empty handed.
It felt nearly impossible to get started on my healing because I couldn’t find any high quality information.
So then there were a lot of things I learned about PCOS over the course of doing several years of research and writing.
In fact, I learned so much that I cured my own PCOS in 2013, and I began curing thousands of other women’s PCOS with my rather ground-breaking (if I do say so myself) manual on PCOS – PCOS Unlocked.
(It really has done some wonders, check it out for yourself @ here if you’d like!)
Anyway. I have since made it my mission to prevent you from suffering the same years of frustration heart-break. To that end, here are the top 5 things I have since learned, that I wish I had known when I was diagnosed with PCOS:
1. You don’t have to be overweight to have PCOS
You do not have to be overweight to have PCOS. In fact, approximately 35% of women who have PCOS are not overweight. If you are not overweight and you have PCOS, you have a lot of friends.
Most women who have PCOS struggle with insulin resistance. This often goes along with being overweight, but doesn’t always.
It is entirely possible to be “normal” or a healthy weight and be insulin resistant. In this case, you will probably still want to work on your insulin resistance for the sake of your PCOS. The best way to know whether that will work for you is to get tested for insulin resistance.
But plenty of women who have PCOS are normal weight and are not insulin resistant. I was one of them. We are the women who fall through the cracks, because weight loss and insulin sensitivity are the two biggest causes of PCOS doctors focus on, almost to the exclusion of everything else.
So you might, but you do not have to be overweight to have PCOS. And there are solutions for you one way or another.
2. There are many different causes of PCOS
Doctors, authors, and most bloggers talk about only one or two causes of PCOS. They talk about being overweight, and they talk about insulin resistance.
But did you know that stress, hypothyroidism, a low carbohydrate diet, under-eating, overexercising, excessive weight loss and low body weight, inflammation, the MTHFR gene mutation, menopause, and birth control pill use can all contribute to PCOS?
Before I came around, very few people ever talked about these causes. But they are very important underlying problems for just about every woman who has PCOS. My own PCOS was caused by a confluence of many factors: low body weight, excessive exercise, stress, hypothyroidism, and MTHFR.
For a resource (or really, the only resource) that covers how to overcome PCOS from all of its various causes, I’m not sure if you could do better than my own.
3. PCOS affects more than your period
When I was first diagnosed with PCOS, honestly, I didn’t really care.
I mean, sure. I didn’t get my period any more. But I actually thought that was kind of a relief.
Little did I know that the longer I let my PCOS go, the worse my hormone levels got. My testosterone and DHEA-S levels kept climbing (this was bad), and my LH, FSH, estrogen, and progesterone levels kept falling (this was also bad).
I developed acne over time. It became very severe.
I lost my libido.
I began sleeping poorly.
I was infertile.
If I had taken my PCOS seriously right from the get-go, I might have avoided all these symptoms. PCOS can also cause male pattern hair growth (like mustaches), balding, weight gain, mood disorders, and early menopause. PCOS is primarily a hormone condition, but it can affect all of your health.
4. PCOS requires patience
Overcoming PCOS takes time. This is in large part because each woman’s PCOS is unique. You cannot necessarily follow the prescriptions written for somebody else. You need to follow your own path.
Following your own path with PCOS means getting tests done, talking with your doctor or other health professionals, doing research, experimenting with different hypotheses you have about what’s causing your PCOS and how to overcome it, and giving your body the time it needs to heal from underlying health conditions.
The thing about PCOS is that it is always caused by an underlying condition. Until this condition is cured, the PCOS will not go away. No medication will cure the PCOS. No wishful thinking. The only thing that can help you overcome PCOS is making the dietary and lifestyle changes you need in order to heal the underlying condition.
5. Sometimes the most important thing is being honest with yourself.
When I had PCOS, I was in serious denial.
I thought: “there’s got to be a cure out there that will enable me to have my cake and eat it, too!”
I kept looking for the secret pill, the magic bullet.
I suspected that I needed to gain weight in order to regain hormone balance, but I didn’t want to. I had worked very hard starving myself and exercising twice daily in order to fit into the body mold I thought was “sexy.”
So I ignored weight gain as a possible cure. Instead I tried taking metformin and spironolactone, two drugs that did significant damage to organs in my body that I still haven’t recovered from. Instead I waited. Instead I kept looking for a different cure.
Eventually I summoned the courage to gain some weight, and my menstrual cycle returned.
You may not have the exact same story as me, but maybe it’s a similar one. Maybe you suspect you need to eliminate grains from your diet but are afraid to. Maybe you don’t want to give up sugar. Maybe you don’t want to give up being a Cross Fit athlete. Maybe your job is really stressful but you can’t bring yourself to leave. Maybe you’re just afraid of change, or lazy.
Sometimes the best thing you can do for your PCOS is simply to be honest. Do some tests, be virogously honest with yourself, and then craft a plan for healing. This, in my perspective, is the best thing you can do to speed up your healing from PCOS. It’ll help you get right down to the cures you need, instead of flailing about hoping things will just get better.
So that’s it for the 5 most important things I wish I knew back in the day.
If I had, I would have saved myself years of both physical and mental anguish.
You can read more about what PCOS is in this post,
or if you already know you’ve got it, check out that manual I wrote for overcoming PCOS, at this link. It’s an immediate download – you could get started on the most effective healing path for you today. !
So what about you? What do you wish you knew when you were diagnosed with PCOS? What about other health conditions? What advice would you give your younger self?
Most women treat PCOS with medication. Usually they do so with birth control pills or with blood sugar regulating meds. However, neither of these options ever solve PCOS.
Drugs may cover up symptoms of PCOS in the short-term, but they are completely ineffective for long-term healing.
But there is one secret key to effective change.
It is a PCOS diet.
Here’s why, how, and what to do about it.
The PCOS Diet: Why
PCOS (read my introductory post “what is PCOS” here) stands for poly cystic ovarian syndrome. It is the condition of having multiple small cysts on the ovaries. It is usually accompanied by elevated male sex hormone levels and irregular menstrual cycles.
Markers of PCOS include acne, oily skin, facial hair, balding, difficulty losing weight, low libido, and missed menstrual cycles and infertility. Not every woman who suffers from PCOS has all of these symptoms, but all have at least a few.
These symptoms are not a result of the cysts on the ovaries themselves. Rather, they are a result of a hormone imbalance in which male hormones are elevated over female hormones.
When doctors proscribe medication for PCOS, they typically have two options:
One is birth control pills. These pills contain progesterone and (usually) estrogen in them. These pills help control the symptoms of PCOS because they increase progesterone and estrogen levels in the blood. Doing so helps restore proper balance between male and sex hormones. The problem with taking these pills is that the underlying hormone imbalance continues to exist. Once you come off of the pill, the chances are close to certain that your PCOS symptoms will come back.
Another is blood sugar regulation. The primary pill used for this is metformin, which I have written about at length here. Metformin sometimes helps (though not always, not all PCOS cases are the same). Even in cases in which it does help, however, it does not heal the underlying problem.
The important thing to know about PCOS is that it is caused by an underlying health condition. If you take medications that cover up symptoms, you are still left with the underlying health problem. In many cases of PCOS (though not all) this is an insulin problem, and may also be a gut problem, or a thyroid problem. All of these problems can cause many other symptoms and diseases in the long-run. In fact it is almost certainly guaranteed to.
The only way to be free of all of these health problems is to make the dietary changes necessary to correct hormone imbalance and heal underlying health conditions.
The PCOS diet: How
I wrote an extensive post about the causes of PCOS here (and an even more extensive book about it here). For a real quick recap, this is what I said:
PCOS is far more complicated than most medical professionals and websites would have us believe. They tell us that PCOS is only a problem of high testosterone and insulin levels.
But PCOS is caused by so many more things! It is also caused by hypothyroidism, by leaky gut, by birth control pill usage, by inflammation…. all of which are problems that can be overcome with dietary changes.
The PCOS diet I describe here helps account for all of those things. I will mention below which specific aspects of the diet are more helpful for different underlying conditions – though all of the points of advice are helpful to know about.
The more you know about your PCOS and what has caused it, the better. That way you can better tailor your diet and healing plan to your needs. I wrote a manual exactly on how to figure out your PCOS that you can read about here. You can also check out this post on PCOS treatment options.
The PCOS Diet: Foods to Eliminate or Limit
From a physical standpoint, it may be best to completely eliminate the following foods from your diet. However, I recognize that this is not necessarily feasible, especially if you have an ambivalent relationship with food and think that an overly-restrictive diet will do you more harm in the long-run.
Restriction, after all, is the primary cause of overeating.
So I advise you to consider these guidelines as firm guidelines you choose. Choose to focus on the healthy foods and to avoid the less healthy foods. Don’t force or punish yourself. Make it a choice – and it will be all the easier to adhere. You may choose (for any number of reasons) to deviate from the guidelines from time to time. Just know also that it’s best to focus on the healthy foods as much as possible.
Perhaps it goes without saying, but this is so important I will say it anyway:
Foods that come in colorful bags and boxes have most likely been “manufactured” to some extent, and contain any number of unhealthy compounds. Trans fats and partially hydrogenated oils may be some of the worst, though all the added sugar in processed foods gives them a run for their money.
Foods that you wouldn’t even expect to be bad are often full of things that aren’t good for you. Breakfast cereals, for example, are usually fortified with folic acid. This was intended to be helpful for pregnant women – but it now instead has been linked to several forms of cancer.
If you instead eat one serving of spinach every day, you would get your daily requirement for folate which is far healthier for you than the chemical altnerative folic acid made in laboratories.
Take a look at the ingredients in whole wheat bread. In addition to being full of gluten and other harmful wheat proteins, for most brands, there is a high amount of sugar and even partially hydrogenated soybean oil in the bread.
Processed foods cause PCOS because they cause nutrient deficiencies and inflammation. They mess up metabolism and make it hard for the body to healthfully detox and metabolize food. Removing them from the diet can do wonders for women with PCOS.
I am a perfectly good fan of fruit, potatoes, starches, and other natural plant carbohydrates. Sugar, on the other hand, in sweets, in soda, in sauces, and in just about everything else from restaurants or packages in grocery stores, is incredibly bad for women with PCOS.
Sugar causes insulin levels to spike, and insulin causes the ovaries to produce testosterone. Therefore many women find that there is a direct relationship between how much sugar they eat and how bad their PCOS symptoms are at any given point in time.
Sugar is not the only thing that can cause insulin levels to go haywire. Having inflammation or IBS or other gut problem can also cause dysregulated insulin levels. But sugar is most definitely one big potential bad guy that should be eliminated (as much as possible).
What’s a seed oil? A seed oil is probably the oil 95% of the food you have eaten in your life has been cooked with, especially if you often eat at restaurants.
Seed oils are used in processed foods and by restaurants because they are cheap nd don’t have a unique flavor, which makes them easy to use in any food product.
Seed oils include vegetable oil, soybean oil, canola oil, rapeseed oil, sunflower oil, safflower oil, and all other oils that come from seeds or nuts.
They are unhealthy because they are composed primarily of omega 6 fats, which cause inflammation. Inflammation is one of the primary causes of insulin problems, hormone imbalance, and PCOS.
Avoid them by avoiding processed foods, and by cooking with coconut oil (my favorite here), olive oil (another favorite here), or ghee (clarified butter) at home.
Unlike most bloggers in the paleosphere, I don’t think it’s necessary for everybody to give up grain products 100%.
However – if you have a gut issue, an insulin issue, or most especially an autoimmune disease like Hashimoto’s Thyroiditis like many women with PCOS do have, you probably do need to eliminate grains at least for a while.
And even for those of us who do not have any of those conditions, grains are still not optimal. The proteins in grains (gluten is one but not the only one) can be harmful to the gut lining. Certain molecules in grains bind with nutrients in the gut and carry them out of the body with excretion. They should not be the staple of anyone’s diet.
Consider eliminating grains for at least a few weeks and see if that helps you! Some women I have worked with have found that eliminating grains was the most important thing they did for their healing. (Though others of course had different problems and needs.)
By grains I mean all bread products, pasta, breakfast cereal, bagels, sandwiches, pizza, etc. Grain-type things that are okay in my book are rice, quinoa, and occasionally corn and oats (though be sure they are gluten free).
Dairy is complicated. Some women need to remove it for PCOS and others do not. This is another food, like grains, that I recommend experimenting with. Remove all dairy – milk, yogurt, cheese, cream, and butter (though ghee is fine since it is clarified!) – for at least 3 weeks and monitor if you experience any changes in your symptoms.
Some women need to eliminate dairy because of its harmful effects on the gut. Others find that doing so helps with symptoms of PCOS like acne because dairy is simply a food that has a lot of male-type hormones in it.
If you have an autoimmune disease or IBS….
If you have an autoimmune disease like Hashimoto’s Thyroiditis or Irritable Bowel Syndrome (or other gut issue) which can all contribute to PCOS, I recommend considering eliminating legumes like beans and peas, nuts, and also the nightshade vegetables tomatoes, potatoes, eggplant, and pepper.
Your best bet as a guide in doing so is Dr Sarah Ballantyne, who’s written the book on autoimmunity and diet. You can find the book here.
The PCOS Diet: Foods to focus on
That may seem like a lot of food to eliminate! No processed foods, no oils, no sugar…. well, really all this eliminates is processed food! (If you get smart at reading labels you can still include some foods that come in bags and boxes… I talk about how to do so in this book.)
All that’s left having been eliminated for sure is grains, and possibly, though not necessarily, dairy.
Then you are left with a literal bounty of fresh fruits and vegetables, healthy cooking fats like olive and coconut oil, and all the animal products you might ever want, from eggs to ribs to bacon and back.
Vegetables are awesome. All of them. They are rich in B vitamins, vitamin E, vitamin C, and many other antioxidants.
Try to have at least one serving of greens like kale, spinach, chard, or broccoli every day. More often than not, cook the greens, as this reduces a potential threat they might pose to your thyroid gland.
Starchy vegetables like potatoes, sweet potatoes, yams, cassava and taro are great choices for meeting your carbohydrate needs (which I consider to be at least 100 grams a day).
Women who struggle with insulin and who are type I PCOS may not want to have a TON of starch, but they should still have at least some carbohydrate – at least 100 grams a day! Women who are type II PCOS and struggle with low hormone levels may instead want to have a LOT of carobhydrate, somewhere around 2 or even 300 grams a day.
Fruit is also awesome! Fruit is also full of antioxidants and vitamins. As with starches, women who struggle with insulin and who are type I PCOS may not want to have a TON of fruit, but they should still have at least some carbohydrate!
I especially love berries, cherries, and other dark fruits like plums for great antioxidant content. Antioxidants improve detox and lower inflammation, which is crucial for overcoming PCOS.
Eggs are super healthy super foods! They contain all of the building blocks for a single organism in them… so they contain a lot of nutrients we can’t really get anywhere else!
In particular, eggs are rich in choline, which supports liver health, helps lower triglyceride levels, and which can help reduce inflammation and metabolic dysfunction.
For women with all types of PCOS I recommend trying to eat two eggs (and the YOLKS, which are the parts with all the nutrients in them) a day.
Seafood, particularly wild caught fatty fish like salmon (a great salmon snack here!) or trout, is great for women with PCOS. Not only does seafood contain high levels of good vitamins like vitamin D and iodine, but it is also the only rich source of the super healthy omega 3 fatty acids EPA and DHA in the diet.
Aim for one pound of fatty fish like salmon every week. If you cannot get that, consider taking this cod liver oil supplement. This is the highest quality and most nutrient dense fish oil available in the world today (not exaggerating).
Seaweed is awesome for PCOS because it contains lots of trace minerals in it, including iodine and selenium, which are great for supporting thyroid function.
For the sake of thyroid health, be sure that if you eat seaweed (here’s a super tasty paleo-approved seaweed snack) or supplement with kelp to eat about 10 brazil nuts (raw organic here) a week, since those are high in selenium and the seaweed is higher in iodine. It is crucial to get both iodine and selenium in the diet as the thyroid needs both in order to function optimally.
Organ meats are some of the healthiest foods around! Did you know that liver contains 20,000 times the vitamin A of the normal vitamin A “superfoods” carrots? It does!
Aim for about one pound of liver consumption a month. If you don’t like liver (but you should, it’s amazing), try 10 capsules of this grass-fed desiccated liver supplement.
Grass-fed animal products
Grass-fed cows, bison, pork, and other animals are great sources of protein and fat, rich in the B vitamins you need to support detox.
Butter from grass fed cows is also great -particularly ghee, which tastes like butter but is safe for everyone (even those of us with autoimmune diseases) to eat.
Great plant fats: Avocado, Olive oil, Coconut Oil, Palm Oil
Olive oil is an amazing plant fat. It is great at low temperatures (but can go bad and be unhealthy at high temperatures), so use your olive oil mostly for cool foods like salads.
Avocadoes are super healthy and high in vitamin E, which can help promote progesterone production, so this is a definite must for women who like their taste buds and have PCOS. 🙂
Coconut oil is anti-microbial and great for fat-burning, as its a fat with a special molecular shape. I already mentioned that this is my favorite coconut oil. It’s great and super healthy for cooking, and fabulous in both sweet and savory dishes.
Red palm oil is another option that is good for high heat cooking if you do not particularly love the taste of coconut oil. Here is the tastiest, in my opinion.
Fermented foods are great for PCOS because they are excellent ways to help support gut flora health, which is crucial for overcoming insulin resistance, cooling inflammation and balancing hormone levels.
Here are some of my favorite fermented foods and great links to get them online: kimchi (korean fermented cabbage), kombucha (fermented tea-careful though because it has caffeine!), and coconut-based yogurt.
The PCOS Diet: How to Eat it
Having a list of foods is all well and good, but you are probably wondering at this point how much and when you should be eating these foods.
Unfortunately, the answer to that question vaires based on which type of PCOS you have. For example, in the manual I wrote (check it out here) on overcoming PCOS, I recommend different amounts of carbohydrate for type I or type II PCOS. I also recommend different meal timing. For type I PCOS, I recommend eating in 3 meals, or perhaps 4 including a snack, every day. For type II PCOS, it is often helpful to eat more frequently than that.
In general, however, here are some good guidelines to follow:
A healthy protein level for women with PCOS is between 50 and 100 grams of protein every day. This is the equivalent of 2-4 cans of fish a day (for sizing purposes), which is also roughly about 3 palm-sized servings of meat a day, 0.5-1.0 pounds of meat, or 8-16 oz of meat.
Many women with PCOS – there are no good numbers out there, though in my best estimate is perhaps between 40 and 50% – have a tendency to have elevated homocysteine levels, as a result of carrying the MTHFR gene mutation. Homocysteine is a by-product of protein metabolism, as well as the body’s detox processes. One of the best things you can do to help keep homocysteine levels in check is eat a moderate protein diet. More than 100 grams/day is probably not optimal for a woman carrying the MTHFR mutation.
(Another thing you can do is take a high quality methylated B vitamin supplement. This methylcobalamin (B12) is good. This methylcobalamin with 5-MTHF is even better for some because the 5 MTHF even better helps support the body’s detox methylation pathway. Always start with a low dose and take it in the mornings since B vitamins can be energizing!)
Plenty of healthy fats
It is optimal to eat at least 36 grams of fat each day, which is about 12 grams of fat per meal (or approximately 100 fat calories). Fat is important for helping the body absorb nutrients, as well as serving as a building block of fatty tissues in the body, like the brain. It also helps keep blood sugar levels stable, which is important for keeping insulin (and therefore testosterone) levels in control.
Aim for one tablespoon of fat at very minimum with every meal.
Plenty of fiber
There is no need to supplement with fiber, or to try to eat high fiber cereals. A diet rich in vegetables and fruits will having plenty of its own natural fiber to give you.
Fiber is great for PCOS because it helps moderate blood sugar responses to meals (it slows down absorption in the intestines), and also because it helps feed gut flora, and also because it helps the body keep digestion moving along at a healthy pace.
At least 100 grams of carbohydrate a day
Some women (usually those who are overweight and/or have insulin resistance issues) find that a lower carbohydrate diet helps manage their PCOS. In this case, they should eat carbohydrate on the lower end, but probably not go much below 100 grams a day. I see far too many women suffer ill effects from a low carbohydrate diet to advocate a very low carb diet for any significant length of time.
Other women should definitely try to stay above 100 grams of carbohydrates like fruit and starchy vegetables every day.
For a lot of people in the paleosphere, 100 grams sounds like a lot. But that’s really just 1/2 a sweet potato or one apple with every meal – a much lower carbohydrate intake than the general population eats.
And I personally eat approximately 250-300 grams of carbohydrate each day – so you are probably lower than I am in carbs!
The PCOS Diet: Healing naturally and flexibly
I have not laid out a specific diet plan. I have not given you meal times or necessary serving sizes.
Rather, I have listed foods that are important to avoid, and foods that are important to focus on, and some rough guidelines for making sure you get enough of the things you need. After you meet these minimum requirements, you can fill in the rest with whatever your heart desires.
(I go into my theory of meal sizes and macronutrient ratios a lot more in my guide to female weight loss if you’re interested!)
This diet is a very nourishing one. Choose a variety of foods from the vegetables and fruits, healthy animal products and healthy fats I list, and you will be eating a diet that is highly nourishing, that reduces inflammation, and that helps support hormone balance.
The best part about it all is that it is long-term, and long-lasting. Medications cannot do that for you. Medications are like band-aids. they might cover up PCOS, but they do not solve it.
The diet I describe here, which I have used personally and used with countless clients all over the world, has literally saved so many of our lives. It gave me my libido back. It cleared my skin. It gave me my fertility back.
The PCOS diet really is a secret to healing – so many women are still missing out on it. So many women still don’t know the amazing effects these easy, natural dietary changes can have on their lives.
The PCOS diet is an incredible tool for overcoming PCOS for good, especially if you’ve figured out your own type of PCOS and what caused it.
You can figure out what caused your PCOS, and tailor this PCOS diet specifically to solving that problem, with the help of my manual for overcoming PCOS, PCOS Unlocked: The Manual.
If you happen to suffer from acne as a result of PCOS — and I wouldn’t be surprised, as the majority of women who have PCOS do — you may wish to check out my posts on acne, or my new, revolutionary program for overcoming acne, Clear Skin Unlocked: The Ultimate Guide to Acne Freedom and Flawless Skin.
You can also check out other posts on PCOS. My favorites are:
PCOS: An Introduction
PCOS and metformin: Everything you Need to know
What Causes and Influences PCOS
And what about you? Have you tried your own version of a PCOS diet? What works for you? What doesn’t? What do you think of my version of the PCOS diet?
Metformin is a type of medication used to treat Type 2 Diabetes. Because there is a strong link between diabetes and PCOS, metformin is now commonly proscribed to treat PCOS. But should it be? What is the real relationship between metformin and PCOS? Can Metformin used for PCOS help lessen PCOS symptoms?
Metformin used for PCOS: The Science
PCOS is an infertility condition that often causes acne, facial hair growth, balding, low sex drive, weight gain, difficulty with weight loss, and mental health disturbances such as depression and anxiety in approximately 15% of women. It is also associated with a myriad of health conditions, spanning from diabetes to hypothyroidism and to heart disease.
PCOS is, in short, not a condition to sneeze at.
PCOS is a condition of hormone imbalance. With PCOS, male sex hormones such as testosterone and DHEA-S rise relative to the female sex hormones estrogen and progesterone. (…Roughly speaking – it’s complicated. For a full-blown account of the science of PCOS and how it affects you, see here.)
Elevated testosterone is very often the primary culprit in causing PCOS. (But not always! For one of my most thorough accounts of other things that can cause PCOS, see here.) Insulin causes testosterone levels to rise because insulin tells the ovaries to produce testosterone.
Basically, elevated insulin causes elevated testosterone, which causes PCOS.
This is where metformin comes into play. Metformin lowers blood sugar levels below what they would otherwise be after a meal. This is because it intervenes with the liver’s interaction with and production of glucose. Insulin is the body’s way of dealing with blood sugar. If blood sugar is lower, then insulin will be lower, and thus testosterone will be lower.
Metformin decreases blood sugar, which lowers insulin, which lowers testosterone.
Metformin used for PCOS: Is it Effective?
That depends on who you ask, and what you are trying to achieve.
Statistically, metformin has been shown to reduce LDL cholesterol (the bad cholesterol) and triglycerides (perhaps even worse for heart disease) in patients with Type 2 Diabetes. It is hotly contested whether metformin has a significantly helpful effect on overall cardiovascular health for patients with Type 2 Diabetes worldwide. It is definitely true that many people have benefited from metformin in terms of their ability to manage sugar and keep insulin levels in check.
In fact, metformin has been shown to help prevent Type 2 Diabetes in people who are insulin resistant and at risk of developing Type 2 Diabetes. BUT – and this is a point I will make several times – it has been shown to be radically less effective than a whole foods diet and moderate exercise. This study compared the two, and diet and exercise were shown to be 34% effective. Metformin, only 18.
Insofar as metformin can help mitigate the symptoms associated with PCOS such as acne and facial hair, it is often quite successful. The evidence supporting this is robust. Metformin used for PCOS does help reduce symptoms in women… at least for those who suffer from insulin resistance.
Metformin used for PCOS: The Limits
There are three primary limits to the efficacy of Metformin for PCOS:
1) Metformin may not be the most effective fertility treatment
So far as your fertility is concerned, clomiphene may be more effective than metformin (and diet and lifestyle more effective yet than that). This is a hotly debated topic in the world of metformin and PCOS. All fertility treatment options should be discussed with your doctor if fertility is your primary aim.
2) Metformin is not as effective as diet and lifestyle in the long run
Just as Metformin loses in long-term efficacy against diet and lifestyle (see my personal recommendations for diet and lifestyle in a blog post or in my PCOS program here) for insulin management and diabetes prevention, so it also loses in terms of managing the symptoms of PCOS.
3) Every person’s PCOS is different – Metformin does not work for everybody
Perhaps the most important point for me to make is that Metformin does not work for everybody.
While many women suffer PCOS because insulin resistance causes their testosterone levels to rise, this is actually only the case for about 70% of women with PCOS. For everyone else with PCOS, metformin’s effects will be minimal at best, and may in fact be harmful.
There are many different things that can cause PCOS other than high testosterone.
- low estrogen levels
- low progesterone levels
- birth control pill usage
- excessive exercise
- the MTHFR gene
- IBS and other gut problems
- and restrictive diets can all contribute to PCOS
If any of these are your primary problem, and not the excess testosterone that comes from elevated insulin levels, other treatments may be more effective for you.
If you do not know what is causing your PCOS, the first step towards getting better is to get some bloodwork done, educate yourself about PCOS and what your personal kind of PCOS may be, and find out!
Other Potential Drawbacks of Metformin used for PCOS
While Metformin does not appear to cause any significant or life-threatening problems, it does come with a host of negative side effects that can are short and the long-term.
The most commonly reported side effects of Metformin are gastrointestinal: at least some of gas, nausea, cramps, bloating, discomfort, and diarrhea are reported in upwards of 50% of cases.
Metformin increases homocysteine levels in the long-term. Homocysteine is a by-product of the body’s natural detox processes, and it is toxic in high levels. Elevated homocysteine has been shown to be associated with inflammation, heart disease, cancer, and just about every non-communicable disease out there (including PCOS!).
Metformin appears to influence thyroid hormone levels, though the mechanism and implications are poorly understood.
Metformin reduces testosterone levels, which can upset hormone balance. I personally suffered severe depression – suicidal depression – when I experimented with taking Metformin. I only had to take it for six days for the storm of sobbing and suicidal thoughts to hit. I stopped taking it, the depression went away, and then I tried again and the depression came back. Obviously everybody is different – but this is a real risk. Anxiety is another threat, as is low libido, poor memory, and sleep quality.
It is also worth noting that in the case of weak kidneys, Metformin can cause kidney failure due to lactic acidosis.
The Real Reason Doctors Proscribe Metformin for PCOS
There are many reasons doctors use metformin to treat PCOS. Most importantly, they know that it has been demonstrated to be helpful for a lot of women with PCOS. Yet it is also important to remember that doctors tend to over-proscribe medication as a general rule.
Doctors and patients both know that it is easier to take a pill than it is to make changes. (It also happens to be more profitable for the doctors, but they are not the only ones to blame here, since patients are usually the ones asking for the pills.)
But is it better?
It has been demonstrated over and over again that the most effective way to treat PCOS is to eat a whole foods diet and to exercise a few times a week. You can get very specific about the ways in which you do this, and I do go into great depth on these strategies in my program on overcoming PCOS here. Nevetheless the most important point here is to remember that dietary changes are healthy, natural and long-lasting.
What are your experiences with metformin and PCOS? Do tell! I’d love to hear if it has worked for you – or what you like better!
The one thing that we talk about most in this community is how to be in hormone balance. How to be fertile. How to enjoy being a woman instead of constantly fighting the basic facts of natural womanhood.
Every day I send emails to women making recommendations regarding food choices, lab tests, and self-love and body image issues. I thought it perhaps best, then, to share with you the differences I have experienced at different points in my life regarding my hormone balance.
Pre-weight loss; pre-exercise-binger; pre-paleo
As an adolescent and very young adult, I had some but not extreme acne. I weighed 137 pounds at my “heaviest,” which at 5’2 is approximately a size 7, and on my larger days a 9. I was also quite stressed out so did not menstruate super regularly, but still menstruated on a fairly regular basis. My periods were not always, though sometimes, incredibly painful, and lasted approximately 6-8 days. I do not have any good photos from the time (and I deleted off of my facebook any of the ones that actually showed my body fatness… choosing to leave tagged only those photos that were most flattered). But here is what I looked like, more or less:
(College “I’m drunk meditating on the side of the road in Beijing” phase)
(College “I’m dressed as a fairy holding the ‘make out’ hat” and “this photo is actually super flattering” phase)
Yet I dug up one from another angle in which I appear a bit less flat:
(Yes, I’m kissing someone, not a phase.)
(College “I’m a crunchy hippy” phase)
In the fall of 2009 I finally achieved the momentum I needed on my low fat, low calorie, vegetarian diet, 90-minute-sprint-workouts-every-day regimen to shrink down to, at my lowest, I think I was probably around 105 pounds. I bounced back up to 115 for the next few years but I still wore size zero, 25 inch waist pants.
In this time period, I experienced:
-the complete cessation and continued absence of anything resembling a sex drive
-an vagina that was, all of the time, as dry as Oscar Wilde (if not more so-if such a thing is possible)
-a completely absent menstrual cycle
-constant hunger (though I did not know it at the time since I had yet to experience the real cycle of intuitive eating yet)
These five bullet points might not look like much – but when you’re a woman who prided herself on her voracious sex drive and then it completely vanished, and you became infertile, and had acne… the thing was, I always suspected that my weight was to blame for my acne, at least in part, but I always thought it still worth the trade off. I’d rather have acne and be thin than be fat with clear skin.
This is what I looked like in this time period:
(“I cover my face because the sun burns my acne” phase)
(“I have eight pack abs, so what, b*tches?” phase)
(“Thigh gap!” phase)
(“Holy crap I’m so comfortable in this tiny body please don’t take it away” phase)
Lots of women probably menstruate at the size I was in the photos above. They probably had sex drives. I did not. All I had managed was to salvage my skin, mostly by reducing the fiber and protein contents of my diet, as well as by adding a topical probiotic to my daily regimen and ceasing to use conventional soaps and such. I had also managed to ovulate a few times, mostly by radically reducing stress or by having a particularly potent sexual encounter, but I did not have a true menstrual cycle, not by a long shot.
I also ate paleo the whole time, so anyone who says all you need to be healthy is a paleo diet is woefully uninformed.
Then came a time in which I prioritized my work and energy over everything else, and was extraordinarily stressed out. I gained weight. fast. And surprise of surprises, I menstruated. (Literally, it smacked me right out of the blue.) My sex drive had steadily increased up until that day, and has remained not just “oh thank god sex doesn’t disgust me anymore” or “well sure I’ll kiss you I guess” but “holy crap I want to do it now” since then. I have continued to cycle since. And my skin has cleared, almost entirely (to be fair: my stress has also been radically reduced), and I have, to my mingled dismay/resignation/fear/acceptance, continued to gain weight.
This is what a Stefani that can menstruate looks like:
(“I’m such a big deal I do photoshoots and holy crap I’ve got hips” phase)
(“Holy crap back fat stomach fat” phase)
(“Bear in mind that the camera on my phone elongates and I’m not nearly this tall or slim” phase)
If you want to see a video of me partner dancing in a body that menstruates (which is, still, a size or two smaller than I am now, I am more than happy to invite you to do so, here).
Looking at these photos, you might hardly see a difference. So what, you say. “She’s not overweight.”
No, of course not. I agree. I mean — there is definitely a difference, and just about everybody in my life has remarked upon it. My thighs are about 3 inches thicker, each. My face “fuller.” My abs, gone. My periods, pain free, and quite short (thanks to paleo!). I used to be a size 26 jean, and last night I wore a 30. I can no longer wear any outfit with carefree abandon — I now have to worry about placement and what the most flattering cut is and how to handle the parts of my that jiggle.
Some people say I look better. I don’t know. Can I compare? I don’t know. I know I look different, and that’s all that has mattered, and all that made this, while on one hand the best thing in my life, also, on the other hand, one of the harder things I have done (at least in 2014 🙂 ).
It’s been a small difference, but I had to read my own writing, and reach out to others for reassurance, and make a deliberate effort to arm myself against the tides of psychological baggage that tells me putting on weight makes me a failure, marks me as lazy, and renders me unfit for love. I believe so strongly in allegiance to our natural bodies, but that does not mean that I still did/do not have to fight for it on my “bad” days. Only because the gains I have had have been so great — I’m never giving up sex again — and because I have such loving, supportive people in my life, and because I’m currently finishing editing a book all about self-love, was I able to fall asleep peacefully at night rather than in a fit of frustrated, frightened tears.
Our society makes it hard. Even at my own relatively small weight gain and size. It makes it hard to “lose ground.” It makes it hard to “backslide.” But that doesn’t mean we give up. We remind ourselves of our own inherent worth, and we push through, and we change the face of womanhood one woman at a time.
I am no longer a fitness champion. I can no longer compare myself to Victoria’s Secret models. But I am different. I’m a new kind of sexy (more about which in coming days). I am me. And I am happy, and fertile, and healthy, and alive.
More questions about PCOS this afternoon! No surprises here. Below are some thoughts on endometriosis and PCOS, quinoa, feeling restricted, allergies, and moving forward with hypothalamic amenorrhea.
If you find that a question you asked me is below and I have not stripped it enough of your personality to post it here, please let me know.
Help! I have both endometriosis and PCOS. I don’t understand– I thought endometriosis was a condition of high estrogen levels, and PCOS a condition of low estrogen levels. What gives?
There are two ways to answer this question. First, PCOS patients can have high estrogen levels, and in fact many of us do. For this reason, you can have both endometriosis and PCOS without rocking the boat of your theory. On the other hand, I also believe it is entirely possible to have endometriosis and to have low estrogen levels. This is because endometriosis and endometrial pain is related to high estrogen levels, but there are a variety of other factors in the development of endometriosis. Having an impaired immune system and inflammation are two big ones on the list. Once those things happen together, and you plant endometrial tissue somewhere in your abdomen (and in all likelihood aided by having high estrogen levels), then you have endometrial tissue that is going to be very difficult to weaken. That is just the nature of the tissue. It does not just shed off effortlessly. In this time period your estrogen levels can drop and your immune system can improve, but your tissue may still cause you pain. This is how you can have low estrogen and endometriosis. The solution is to mitigate the problems as best you can, reducing stress and inflammation, healing your gut, boosting your immune system, and eating a hormone balancing diet such as the paleo diet.
I wrote about endometriosis at great length here.
I stumbled upon your website researching the Paleo lifestyle and was pleasantly surprised to see the tie in to PCOS! I’m sure you’re wondering why I’m commenting on this article but being an avid consumer of marijuana, I had to click and read. Admittedly, I was quite disappointed in what I read not about marijuana but more about seeds, nuts and quinoa. I was under the impression that quinoa was NOT a grain but rather a seed. I’ve successfully omitted all grains, beans, soya from my diet and this was a major bummer to read. I am feeling very deprived right now thinking of the possibility of having to omit this as well. Thank you for the great article however and keep up the great work.
Quinoa is in fact not a grain. It is called a “psuedo cereal” because it does not come from grains or grasses, but is rather the seed of a plant. It is gluten free. That being said, it also has many properties that seeds do, such as having a relatively high amount of phytoestrogen content (and will contain many of the phytates inherent to legumes, beans, and grains all). Phytates are also a bit of a problem for PCOS because they have the potential to limit calcium and magnesium absorption– two ions quite crucial for the development of healthy and fertile corpus lutea. All of which is to say that seeds are not great for PCOS, but unless you are eating buckets they will not make or break your case. Probably, at least, in my opinion.
My thoughts about restriction are of course always complicated. If quinoa is something that is necessary for you to feel good about food and your body, then I advocate keeping it in your diet at least for a while. Clean up as much as you can, and relax into your food choices. Try eating less whenever it seems easy to do so. If it’s a battle, don’t fight it. Just phase it out only as you can let it go with peace. This will happen over time with patience and with love. And if it does not, I really think that’s okay, too. Take care of your brain first and foremost. It is going to be your most important tool by far for taking care of your body for the rest of your life.
I have question. I had a hysterectomy in May 2012. I struggle with endometriosis, hashimoto’s, Sjögren’s syndrome & celiac. I’m on estrogen therapy & the autoimmune protocol but my allergies are getting worse! I eat meat, non starchy vegetables & fruit. I can’t tolerate any spices or starches & my allergies continue to worsen. Any suggestions?
You may wish to try eating a GAPS diet to heal your gut further. Allergies are not my specialty– but I highly recommend first doing everything you can to assist your immune system, since this is where allergy problems are rooted. This includes reducing stress, getting as much sunlight and/or vitamin D as possible, eating organ meat often–I’d advocate at least once each week–getting as much sleep as possible, and potentially getting your micronutrient levels checked to see if you have any deficiencies that are hindering immune function. Boosting immune function will help your immune system react appropriately to foods without leaping into panic mode. It also depends very much on what your allergies are and how you are reacting to them. Are they definitely allergic reactions, or are they food intolerances? This is a crucial difference. An allergy is rooted more in immune issues and food intolerance is rooted more in the gut. Allergen-specializing docs are probably the best place to go for troubleshooting this sort of issue. You also want to make sure you are taking care of your hypothyroidism appropriately — are you supplementing with thyroid hormone? because with Hashimoto’s you may need to be, so speak with your doctor about it — because thyroid hormone is crucial for immune function, for cellular repair, for probably energy usage, and just about everything else cells do.
I have had HA since february, since I stopped taking the birth pill. I am really underweight (5’10 and 100#). I lost a lot of weight when I started crossfit and doing a low-carb diet for two years. I am now trying to conceive. My hormone levels are all very low. I haven’t worked out for several months. I only walk daily for one hour. I started seeing a therapist about my anxiety, who is helping me gain weight. She makes me track my calories in order to gain weight. I have to eat more than 2,000 calories but rarely go over. I am a bit scared of carbs. Gaining weight is not working although I eat more and stopped working out. I keep counting the carbs and feel bad having potato chips and a cookie (too much carbs). I do eat a good amount of fat (teaspoons of coconut oil, nut butter bacon, greek yogurt etc…). What should I do?
Since your primary concern– and biggest obstacle– in getting pregnant is convincing your body that you are fed, you want to err on the side of eating more rather than less. This should be the case all of the time. Also, I recommend that you eat whatever you want. Anything you want. I personally eat a very high carobhydrate for extended periods of time to zero ill effect. Do your absolute best to stay within the range of non-toxic foods (ie, skip the gluten, deep fried foods) and eat heartily. The more frequently you can hit your 2000 mark, or even better, go over, and the less you obsess, the faster you’ll regain hypothalamic health.
I cannot stress to you how much all of the factors of relaxing, reducing your anxiety, and gaining weight are all important for your ability to conceive. This takes a lot of work. You are going to have to have patience, and to forgive yourself as much as possible for all of the difficulty you are having moving forward. The thing is that it is not your fault. You have become inordinately thin as a result of psychological pressures put on you by an external environment, and now you are stuck with fighting that. Keep your chin up and move forward as lovingly as possible. Accept yourself as a natural body with natural needs. When you look in the mirror, don’t obsess. As a matter of fact, don’t look in the mirror. It is way too easy to start seeing ourselves as bigger than we used to be– and even while we need to gain weight to be and even look healthier, by the simple fact of being “bigger” we think we look huge. Don’t let your brain trick you into such radical subjectivity. Do your best to put your evolutionary need and your fertility at the front of your mind, and be excited when you see yourself put on a bit of weight. Do it slowly and make sure to protect your brain in all of this, but embrace your needs. You are a woman with some strong ovaries and the power to carry children. Nourish yourself as your body is crying out for, and take as much pride in that as possible. Being thin doesn’t make you worthy. Being a badass and tackling these problems with as much love and determination as possible does.
Eat carbohydrates!!!! Carbohydrates a) do not make you overweight, they just don’t, period, and b) are supremely healthful for you, especially in a state of metabolic distress. Start eating them slowly and learn bit by bit the lessons I am telling you. You will see that they make you feel and look better without making you balloon in some ridiculous fashion. They are just food, same as fat and protein. Period. Eat them whenever, however, and however much of them as you want.
Be patient, however, love. These things can take time depending on how much damage has been done and how diligent you are about allowing some weight gain and calorie intake. Increase what you are doing as much as possible, and make sure that you are erring on the side of nourishing yourself more rather than less. Believe it or not you have already made radical progress. You have started therapy– something most women never do!– and you have admitted that you need to work on some of these issues. And you have really cut back on your exercise, and you are working on eating more and gaining weight. These are all awesome things. You are doing it, and you have so much to be proud of moving forward. You will get there, especially with love, forgiveness, and harmony with your natural body on your side.
You can read more about my work and opinions and plans for PCOS in the manual PCOS Unlocked.