Lifestyle intervention
Every guideline I’ve ever come across for PCOS cites ‘lifestyle intervention’ as the first-line treatment, although doctors have not always been famed for giving the best lifestyle advice. Thankfully, times are changing and there is a new wave of doctors coming on to the scene, led by the likes of my friends Dr Rupy Aujla, Dr Hazel Wallace and Dr Rangan Chatterjee (see Resources), all of whom dish out great lifestyle tips via their social-media platforms and chart-topping podcasts, so check them out.
Several years ago, a hugely overweight twenty-two-year-old came to clinic for advice about PCOS as she was planning on getting pregnant in the next few years. I spent about fifteen minutes talking to her all about lifestyle interventions that she could undertake. I gave her so many in-depth, practical tips and tricks that she could use to improve her PCOS and, in turn, her long-term health in general, which is so important for anyone planning a pregnancy, with or without PCOS. My heart sank though when she looked at me and said, ‘But can’t you just prescribe me a tablet to sort it all out?’ Granted, these interventions are not easy, requiring some hard work and diligence at times, but you will reap the benefits in the long term because they can reduce the risk of the complications of PCOS, including type 2 diabetes and heart and vascular diseases, which are some of the major causes of death and chronic-health issues in the Western world.
Here is a summary of the advice that I give to my patients (see Part Five, here for more details).
Weight loss Many patients are surprised when I tell them I’m not going to ask them to lose weight. Weight loss is one of the most effective ways to help the symptoms of PCOS (reducing fat reduces insulin resistance, which is the main driver of the condition), making your cycles more regular, increasing the chance of a healthy pregnancy, improving acne and reducing the risk of diabetes and heart disease in the future.11 However, being told to lose weight is psychologically tough and, I believe, makes the whole disease much more traumatic to deal with. I prefer instead to focus on improving diet and exercise which, if done correctly, will result in both improved symptoms and weight loss without this being a depressing focal point.
Diet There are a lot of people pushing extreme PCOS diets online, particularly focused around low-carb/ketogenic (high-fat, low-carb) diets, which I don’t subscribe to at all. The rationale behind them is sound, and data supports short-term effectiveness.12 But we don’t know for sure if these diets have a direct impact in the long term, and they’re hard to stick to, so I don’t recommend them unless a patient is insistent on trying. I also don’t want to promote faddy eating in young, impressionable women, who are already at a higher risk of eating disorders.13 Low-carb diets also run the risk of resulting in a low-fibre intake, which is associated with a higher risk of PCOS.14To get enough fibre, you need to eat carbs. Carbs are not the devil, but the devil is in the detail. You need to eat good-quality, high-fibre carbs such as oats, brown rice and fruits and veggies that are also packed with other precious nutrients that your body needs for all the complex chemical processes such as ovulation. Good-quality fats (see here) are also essential because female hormones are made from cholesterol that is a fat. If you don’t have the building blocks, you can’t make the goods. The Mediterranean diet really is the one that has it all (see here for more on that).
Exercise Probably one of the questions I am most frequently asked online is: ‘What’s the best exercise for PCOS?’ And my honest answer is: the one you’re going to stick with – because dealing with PCOS is about being consistent. And exercise doesn’t have to happen in a gym either; so for many people, something as simple as going for a walk at lunchtime or getting off the bus a few stops early may be exactly what they need and what fits with their schedule. If you want to get geeky about it, one of the main aims of exercise for PCOS is to slightly alter body composition to increase lean muscle and decrease fat tissue (see Chapter 15). Muscle is much more sensitive to insulin compared to fat, and also needs more energy, so improves your metabolism.
Relaxation Life is stressful. Stress increases cortisol, which increases insulin resistance and testosterone levels. If you can remove the driver, you can break the cycle. Realistically, we can’t take all the stress out of our lives – and nor should we, as a certain amount of stress is good for us – but we have to look for ways to manage it. Depression and anxiety levels are also known to be higher in women with PCOS,15 so self-care is very important. Exercise is a great way of addressing self-care and helping you to relax.
Sleep Lack of sleep makes you more insulin resistant, as well as causing cravings for sweet, fatty, high-calorie, low-nutrient foods and caffeine, all of which spike cortisol. And the vicious PCOS cycle continues to turn. I find that exercise helps me sleep better, so as you can see, all the things in this section go hand in hand.
Medication
This isn’t an exhaustive list, but these are the three types of medication that I get asked about the most:
The Pill The combined oral contraceptive Pill (COCP) will not ‘balance your hormones’. While it is entirely acceptable to use the Pill to ensure you have a regular monthly bleed, or as contraception, it will not treat the underlying cause of your irregular cycle. Once you decide to stop taking the Pill your periods will likely still be irregular, unless you’ve made some serious lifestyle changes. I see a lot of patients in clinic who are very disappointed to hear this as they’re under the impression that by using the Pill, their PCOS is cured; it isn’t. The Pill just forces the body to bleed on the week off.Many women are not keen on taking the Pill, but it is advised to have at least four periods per year to reduce the risk of the uterine lining becoming too thick and irregular which can, in the long run, increase the risk of endometrial cancer. The other advantage of the Pill is that it helps your body to make something called ‘sex hormone-binding globulin’, which mops up excess testosterone, so helping with acne and excess hair.
Metformin This is a diabetes medication that reduces insulin resistance. A lot of women tell me they hate it though because it can cause awful stomach cramps and diarrhoea. While metformin can be effective for improving ovulation, body weight and composition, it works best when used in conjunction with lifestyle modification.16
Inositol This is a dietary supplement that can be bought over the counter. Of all the many supplements that have been proposed for use in PCOS this one seems to get the most coverage online and, thankfully, has the biggest evidence base, relatively speaking. I’ve seen a really positive effect from inositol in quite a few women; however, although lab studies suggest it may reduce insulin resistance, and there has been a handful of small human studies to show it can improve menstrual-cycle regularity, reduce testosterone and even increase the chance of pregnancy,17 there haven’t yet been any big trials to prove exactly how effective it is, the best type to use or the optimum dose, so it’s not something that’s routinely recommended by many gynaecologists just yet.
THINGS YOU’VE ALWAYS WANTED TO KNOW, BUT WERE TOO AFRAID TO ASK
When should irregular periods be investigated?
There is no hard-and-fast rule. A sensible approach would be to see your GP if you are having periods less often than every three months, or if you’ve recently started having an irregular cycle. A lot of patients