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PCOS: An Introduction

April 16, 2012
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What is PCOS?  Other than “nasty but not the worst thing in the world”?

PCOS stands for Polycystic Ovarian Syndrome.  Though it’s hard to define because the symptoms people suffer vary widely, roughly four percent of women still have it worldwide.  Up to 15 percent of women in the states. PCOS is the leading cause of infertility in the Western world.

PCOS is a disorder of the endocrine system.   It is characterized by the appearance of multiple small cysts on the ovaries, which is almost always accompanied by elevated male sex hormone levels and decreased female sex hormone levels.   The male sex hormones, called androgens, are testosterone, the many varieties of testosterone, and DHEA-S.  The female sex hormones are all of the varieties of estrogen and progesterone.   This imbalance results in a number of problems.  These include :

-Oligo- and anovulation

-Irregular or absent menstruation


-Increased risk for metabolic symdrome, diabetes, heart disease, and ovarian and endometrial cancers

-Male pattern hair growth (hirsutism)

-Male pattern hair loss (alopecia)

-Weight gain and increased difficulty in losing weight

-Adult acne.


In order to understand how menstrual dysfunction occurs, it is important first to review normal menstruation:

The first day of a menstrual cycle is the first day of bleeding.  During this period, the lining of the uterus is shed.  This bleeding constitutes the first 3-8 days of the first half of the menstrual cycle, which lasts about two weeks and is called the follicular phase.  During the follicular phase, levels of estrogen rise and make the lining of the uterus grow and thicken.

Detecting elevated estrogen levels, the pituitary gland increases its production of follicle-stimulating hormone throughout the follicular phase.  This hormone stimulates the growth of 3 to 30 follicles.  Each follicle contains an egg.  With time, the levels of FSH decrease, so only one of the follicles continues to grow.  It produces estrogen, and other stimulated follicles break down.

Detecting this shift, the pituitary now releases luteinizing hormone.  This makes the follicle bulge and rupture, releasing its egg.  This is ovulation.  During ovulation, testosterone, that is otherwise constantly produced at low levels by the ovaries, surges, and estrogen drops.  Estrogen is required for serotonin production, which is why many women might experience depression during this time.

After ovulation comes the luteal phase.  Here the ruptured follicle closes and forms the corpus luteum.  This makes the endometrium thicken, which produces progesterone.  Estrogen is on the rise again, too, after ovulation.  But if the egg is not fertilized within about two weeks, progesterone levels fall, which triggers shedding and bleeding.  Here the cycle begins again.  Cycles are generally “known” to be 28 days long, but the length of a regular, healthy cycle can vary from ~20 to ~35 days.


Doctors are not sure where the problem enters into the picture with PCOS, but it probably varies.   Some options are as follows:

-Low levels of the hormone sex-hormone binding globulin, a “result” of PCOS, decreases the rate of conversion from testosterone to estrogen.  This might make estrogen too low to send the proper signals to the pituitary.

-High androgen levels coming right from the ovary or from the adrenal glands can block estrogen and progesterone activity.

-Insufficient pituitary signaling with LH or FSH could be the primary problem.  In PCOS, the ratio of LH to FSH is typically around 2:1, instead of the more normal 1:2.  This is presumably because the PCOS patient’s pituitary gland wants her to menstruate but she simply is not.

-Finally, the one hormone that is absolutely crucial for menstruation is progesterone.  When looking at all of these issues, it is a break in the line towards progesterone production that is the likely cause of disordered menstruation.   Without progesterone, the corpus luteum never “knows” when to shed.

In all cases, it’s all very complicated.  The question is a tricky one.  Therefore, it’s important to test testosterone, DHEA-S (the testosterone precursor, an androgen), estrogen, progesterone, LH and FSH at the very least when trying to figure out an endocrine problem.  A liver panel, fasting glucose levels, thyroid tests, micronutrient levels, and adrenal hormone such as cortisol are all important for background endocrine understanding.


Some people in the world of evolutionary medicine posit that PCOS is present in the world today because it was evolutionarily advantageous in a hunter-gatherer environment.  This hypothesis falls in line with the “thrifty gene” hypothesis, which states that those humans who are best at conserving energy are the best at reproducing.  In this instance, an obese woman, or a woman with PCOS, would be able to always have babies during a famine because she is so good at storing and using fat.  The “famine” stage for her makes her fertile.  The times of plenty, on the other hand, would make her infertile.  This hypothesis might work with overweight PCOS patients, but it doesn’t account for the million PCOS patients who aren’t overweight.

And most importantly, just like with diabetes, solely because PCOS may have provided an advantage in evolutionary times does not mean we do not want to treat it as a medical problem in contemporary society.

In the next post, I’ll cover the apparent causes of and influences on PCOS.


For more information on PCOS, why you have it, and how to overcome it, check out PCOS Unlocked: The Manual, the multi-media resource I created in order to share all the PCOS information and experience I’ve amassed in my brain, and apply it to solving the unique case of your PCOS.



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Managing director of Paleo for Women and author of Sexy by Nature.


  1. I am so excited for this site! I’m currently struggling to lose a lot of weight and get a natural cycle back with PCOS, but it seems paleo is putting weight on me?! :(

    • Hi Michelle,
      That depends on what foods you’re eating, and how, on your paleo diet. Hopefully my other posts will help you a bit with that– otherwise, fill me in a bit more here and I’ll see what I can do to help.

  2. Thank you, Pepper :) I’m 5’5”, 204lbs (the Paleo cycle I’m about to describe got me from 187 to 204!). So this is what happens: I go strict paleo (lots of greens, coconut oil, butter, organic meats, poultry, fish… and low carb) for about a week. I get extremely ‘down in the dumps’, which is very unlike me, and I my face starts gaining weight, and above my waist (back, arms, neck) starts gaining weight. So after a week of tolerating that I have a safe starch (or a non-safe starch) and I literally deflate! My stomach gets flatter and I get happier. After a few days of eating starches again my blood sugar swings come back and I start to gain weight again! I completely believe in the Paleo philosophy, but I can’t figure out what the h*** my body is up to. I’m starting metformin soon and am not on any other meds.I don’t overeat past full. I hate to say it, but it seems the more meat and fat I eat, the more weight I gain :(

    • When you began eating starches again, how much starch was it? I think there is a happy balance for everybody– it just takes some troubleshooting to figure it out. I’m sure you’ve thought of this, but I thought I’d run it past you again.
      I have some remaining questions. You can answer them or just think about them and try to tailor your diet appropriately.
      Have you been tested for insulin resistance? How much do you exercise?
      From my perspective, calories matter. I think we should always eat to satiation, but sometimes when our metabolism’s are dysregulated, satiation occurs after a point of weight maintenance. You don’t want to signal to your body that you are starving, but you do want to make sure you are hungry before you eat. Try alternating between average calorie days and lower calorie days, and see if that helps. I’d also recommend intermittent fasting– or at least trying it. For some people who are trying to lose weight, it really works wonders. If you find that it doesn’t work (say, just making sure you go 15 hours between dinner and breaking your fast), then go the alternate route and try to eat fewer, smaller meals. I find that smaller meals works better for me. I have always had a lot of stress circulating in my system, especially with regards to food and how much I am eating, so its important for me to eat regularly to convince my body I am not starving, and to convince it it doesn’t have to store every ounce of the food I eat.

      • Thank you! I was told I automatically have IR since I have PCOS (and I do get blood sugar swings)… but was never tested. I will try the frequent small meals. I find in paleo blogs and books it seems the guys lose all the weight and eat whatever they want. I was trying to do this but it wasn’t helping. I’ll keep what you said about calories in mind. Thanks!

    • I have another idea for you to consider. Dr Ron Rosedale, a low carbohydrate advocate, makes an important point that saturated fats are harder to burn than other fats. This is because they’re almost always larger. Mitochondria have a harder time burning the longer fats, and Rosedale asserts they can’t really burn anything (at least not without breaking them down first) longer than 12 carbon molecules. Most saturated fats are longer than that. Coconut oil is a unique saturated fat, and is mostly a medium chain fatty acid. This is partly why people such as Paul Jaminet recommend eating coconut oil for weight loss. So coconut oil is a good fat to focus on, as is all of the shorter chain fatty acids. Mono and poly- unsaturated fats such as olive oil and omega 3s in fish are helpful.
      So Rosedale advocates staying away from saturated fat for at least the first few weeks of low carb dieting, while the body takes time getting used to burning fat.

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  5. Hello,

    I’ve been tested for PCOS in the past – testosterone, estrogen, and an ultrasound, with negative results. However, I have multiple symptoms. Up until very recently I was of low normal weight, but had very irregular periods, hirsutism, and acne. This past year I have gained a lot of weight due to stress, overeating, and lack of exercise. I have slowly been adapting more and more Paleo into my life recently to overcome disordered eating patterns, and it has been very healing. I am wondering if Paleo can help treat my PCOS symptoms as well. The irregular periods and acne don’t bother me as much (I use topical medications for the acne.) However, the hirsutism is more uncomfortable. Do you have any dietary or supplement recommendations?

    I also switched from running to Crossfit which is where I started gaining weight. I stopped doing Crossfit after 3 months because I didn’t like the changes that were happening. I don’t know it was all mental, or if my body gained muscle more than others, or if maybe I just needed to gain. Regardless, I am wanting to incorporate more exercise into my life and don’t know where to start. There are so many mixed message about what is “best.” What do you suggest for stress regulation, physical fitness, and a Paleo lifestyle?

    Thank you,

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