Hello again! It’s been a while since I’ve written – sorry! I had three trips to the US to teach in June (thanks NY, Chicago and Washington!) and then in July, I was whisked away by the fabulous Fiona Rogers of pelvicfloorexercise.com.au for my 3rd (!) Down Under teaching tour – we held courses in Singapore, Perth, Sydney, Tasmania, the Sunshine Coast and Christchurch – we had an AMAZING time – and I even got some unsupervised time in bookshops….I’m heading off to Boston to teach this weekend but I wanted to get back in the groove of writing again so I asked the amazing Holistic Core Restore coaches, whom I’m delighted and honoured to support, what topic they’d like to explore, either PCOS or Dysmennorhea, and as you may have guessed from the title of this post, they chose…PCOS!
What is PCOS? Polycystic Ovarian Syndrome
Originally regarded as a syndrome where the ovaries produced multiple follicles but they didn’t mature properly, giving the appearance of a ‘string of pearls’ on imaging but we now know that many women who have PCOS don’t have cysts on their ovaries, so “polycystic” can be misleading. You might have cysts, and you might not. There might be acne, increased weight gain around the middle of the body, irregular or painful periods and excess hair growing in places you might not want, such as on your face or your breasts (‘hirsutism’). There may be darkened skin (‘acanthosis nigrans’) around the skin creases of your neck, armpits or groin. Headaches, sleep disturbances, sleep apnoea or feeling ‘TATT’ – Tired All The Time – not uncommon either unfortunately.
Polycystic Ovarian Syndrome has been described as ‘the most common endocrine disorder in women of reproductive age, spanning adolescence through menopause’ but it is still so misunderstood and under-recognised. Dr Aviva Romm has written ‘…‘No one really knows what causes PCOS, though there are many theories – at first it was thought to be caused by sex hormone imbalances, but we now know that the condition is caused by insulin resistance.’
And why does Insulin Resistance matter, you may ask?
Insulin stimulates secretion of testosterone by the ovaries, and inhibits hepatic sex-hormone binding globulin (SHBG) production leading to increased circulating testosterone – this accounts for the acne, facial hair, and male-pattern hair loss in many women with PCOS – and PCOS is considered to be a harbinger of metabolic syndrome and Type 2 Diabetes.
There are a number of pelvic health issues associated with PCOS (pelvic pain, abnormal menstrual bleeding, anovulation and infertility) as well as global health issues such as Type 2 Diabetes Mellitus, Hypertension (you know how I feel about women and heart disease!), Gestational Diabetes (bigger babies, perineal lacerations and an increased risk of Mum developing Type 2 Diabetes in later life) as well as an increased risk of Endometrial Cancer.
What causes PCOS?
There are a number of theories as to what causes PCOS – from Hypothalamic amenorrhea (meaning the communication between the hypothalamus – pituitary – ovaries is disrupted) causing a lack of ovulation and menstruation. This is most common with women who are underweight, extremely stressed or over-exercising. There’s also a possible link to Oral Contraceptive pills – OCP-induced PCOS – where periods were regular before starting the birth control pill, but absent afterwards along with some signs of PCOS such as acne, a high LH to FSH ration and possibly cysts on the ovaries. Often referred to as ‘True PCOS’ – this is where periods were irregular before starting the birth control pill, and other signs of PCOS such as insulin resistance, hirsutism, acne and ovarian cysts are likely present too.
Not to over-simplify, but PCOS is due to an imbalance in the relationship between our sex hormones, in this case testosterone and oestrogen, our stress hormones, especially cortisol (which loves to encourage weight gain around the middle of our bodies, as well as cause cravings for food high in fat and sugar as part of our stress response) and Insulin, which is of course designed primarily to help us balance blood sugar, but is also a super potent fat storage hormone. This dysfunctional relationship can lead to a panoply of symptoms, grounded in inflammation, reproductive dysfunction, abdominal obesity, excess hair growth and insulin resistance…but that’s actually the good news….
Because we have a number of evidence based approaches for decreasing Insulin Resistance, increasing Insulin Sensitivity, improving bowel function (what, did you really think I’d get through a blog post without talking about bowel health?!) and improving our stress response (less cortisol, more serotonin and dopamine!)
How? Lifestyle Goals!
1. Nutrition: Focus on whole, real, fresh foods
Eat regular, blood sugar balanced meals that include good quality protein, healthy fats, and vegetables (especially my favourites, the dark green leafy cooked cruciferous – broccoli and cauliflower, I’m talking to you!). A Mediterranean style diet, mostly plant based, with oily fish a couple of times a week and plenty of nuts and seeds (and avoiding processed carbs and added sugar) is going to do a couple of things for women with PCOS (and actually all of us…). It can help us avoid the blood sugar spikes (hello insulin rollercoaster!) and just as important, we know that women who eat a primarily plant-based diet tend to have bigger better bowel movements – which helps our bodies excrete excess hormones. Because, yes, sometimes, size DOES matter, and when it comes to stool size, bigger is better! (remember, we want to aim for a nice Type 4 on the Bristol Stool Scale, ‘smooth and soft, like a sausage or a snake’. Did I also mention the anti-inflammatory, anti-oxidant, nutrient powerhouses that a diet rich in colourful fruit and vegetables provides? Healthy fats are essential building blocks for reproductive health – so avocados, extra virgin olive oil, nuts and seeds all provide the building blocks for restoring healthy hormone production, especially progesterone, which is an essential component of reproductive health for women.
2. Manage your Stress
As long as we are alive, there will always be stress to be managed, but with PCOS we might also be dealing with the added stressors of facial hair, weight gain around the middle and infertility. Optimising our stress response – taking a deep breath instead of giving in to cortisol telling us to inhale chocolate ice cream, practising mindfulness based meditation instead of allowing the rage and fear and panic to overtake us…these strategies may be useful, or going for a walk outside, or putting on a favourite piece of music, (whatever works for you!). Essentially, we want to start re-directing our hormonal production away from cortisol and adrenaline, which can feed into inflammation and insulin resistance and instead focus on allowing the hormonal building blocks to be directed towards progesterone rather than stress hormones. Making sure that we add in regular mini breaks throughout the day, pausing to take a breath, noticing the warmth of the sun, the smell of the flowers on our desk, using the good china rather than saving it for ‘special occasion’, creating delicious healthy food…There are lots of great apps out there as well, to help us remember that stress management is an essential part of mental and physical AND hormonal health – I’m currently using both Calm and Insight Timer, with surprising regularity!
There are two main exercise strategies that have been shown to be specifically helpful for PCOS – and I’d recommend adding and alternating both. The first is HIIT or High Intensity Interval Training: Almenning et al did a study in 2015 to assess the effects of high intensity interval training and strength training on metabolic, cardiovascular, and hormonal outcomes in women with PCOS.
They found that High intensity interval training for ten weeks improved insulin resistance & body composition improved significantly after both strength training and high intensity interval training.
We know that HIIT training improves insulin sensitivity generally but it is always nice to see a study looking specifically at the condition we’re discussing, right?!
The beauty of HIIT is that almost any exercise can be made into a HIIT type exercise – walking/ running fast for 60 seconds, then walking slowly for 30 seconds, could just as easily be replaced by squats or star jumps, as long as there is good form and no breath holding please!!
I think it is important to note that the high energy HIIT training will ideally be balanced out by a more restorative and digestive system friendly strategy – like yoga! We already know that yoga is beneficial for constipation and IBS, so it is hardly surprising that we would see evidence in the literature that it is good for PCOS too. Ratnakumari’s 2018 study along with many others show the benefits of including yoga as part of a movement strategy to improve the symptoms of PCOS – is it the twists and stretches that improve digestive function? The breathing and pelvic floor connectivity that helps centre the person? The emphasis on breathing and relaxation that helps decrease cortisol production and improve the stress response? Or all of the above?
Medical management of PCOS has traditionally been focused on Metformin and/or oral contraceptives but by optimising lifestyle (‘Control the Controllables!) we may be able to help women, as part of their multi -disciplinary healthcare team, decrease their dependence on these pharamaceuticals (and their side effects…) and with the help of their doctors, hopefully even wean off them.
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Until next time
Onwards & Upwards!
(if there are any topics you’d like me to cover, let me know on fb (michelle Lyons Celebrate Muliebrity) or over on Instagram (michellelyons_muliebrity)