PMOS Part 2: Functional Medicine Treatment
The conventional treatment of PMOS Polyendocrine Metabolic Ovarian Syndrome (formerly known as PCOS) is often focused on reducing the androgens and treating the metabolic dysfunction (hyperinsulinemia and insulin resistance) which are hallmark features of the condition. The management often includes use of birth control pills, diabetes medication such as metformin and anti-androgenic medications such as spironolactone. This makes sense if you look at the pathophysiology outlined in Part 1.
In the Functional Medicine model, we like to go upstream to further look at and address the root causes of the issue as it pertains to things such as lifestyle, the microbiome and toxic burden. This is extremely empowering and important given the other associated conditions with PMOS / PCOS that can affect quality of life. If we understand the pathways that lead to the endocrine imbalances then we can have the opportunity to reverse it or impact the severity.
Lifestyle Considerations for the treatment of PMOS
Nutrition
Food plans that are lower in glycemic load and index are beneficial in the pathophysiology of PMOS given the fact that hyperinsulinemia is a key driver of the androgen production in the ovaries. Therefore limiting foods that raise blood sugar makes sense in the management of PMOS. The eating patterns best studied specifically are the Mediterranean Diet which has the key feature of being high in fiber and inclusive of healthy fats which offset rise in blood sugar from a mixed macronutrient meal. It is whole foods based and minimized processed food which often has added sugars. The second food plan studied for PMOS is a ketogenic eating pattern which is low in carbohydrate and higher in fat content. There is mixed data on the long term sustainability of the ketogenic food plan compared to Mediterranean eating patterns however both have been shown to reduce biomarkers of PMOS and reduce symptoms.
Timing of eating in alignment with the circadian is also beneficial. Fasting at least 12 hours in a 24 hour period when the sun is down is helpful for insulin sensitivity. A step further would be extending the fasting period to 16 hours in an effort to improve metabolic health, reduce caloric intake for downstream effects on hormone balance over time. Efficiency of the digestive system and the mitochondria and the metabolism are connected to the light and dark cycles so as a rule of thumb – eating during daylight hours makes sense.
Exercise
Exercise and movement and modern more sedentary lifestyle seems to play a role in susceptibility to metabolic dysfunction and thus PMOS. The treatment plan for PMOS in the functional medicine model should include physical activity which encompasses both cardiovascular exercise and strength training per standard guidelines. The “dose” of exercise should be at least 150-300 minutes per week of moderate intensity aerobic activity or 75-150 minutes of vigorous intensity for the cardiovascular exercise paired with resistance training at least twice per week.
Sleep
Quality and quantity of sleep affects the endocrine system including insulin and blood glucose regulation. There is a connection between sleep, adrenal function (stress response) and androgen production. In fact some women with PCOS features have normal testosterone level but high levels of other androgens such as DHEA-S (dehydroepiandrosterone sulfate). In addition, poor sleep drives food seeking behavior and contributes to obesity risk.
Non Pharmaceutical Interventions for PMOS
Probiotics and Probiotic/ Prebiotic Functional Foods
Microorganisms that reside in the intestines affect metabolic health and endocrine health. It is common for gut bacteria diversity and quality to degrade over time. Eating foods that have commensal or friendly gut bacteria can be preventative and a treatment for glucose dysregulation. We are learning more about specific strains of probiotics for treatment and that data is evolving. The strains that have the most evidence for improving biomarkers in PMOS are blends of lactobacillus and bifidobacterium.
Prebiotic fiber which can be found in food and in supplement form can also benefit PMOS by way of supporting friendly commensal microorganisms in the gut. Resistant starches such as inulin have been studied in PMOS and found to be beneficial for symptoms and laboratory data including insulin and testosterone. A food source of inulin for example is chicory which is a staple in the traditional mediterranean diet.
Inositol
Inositol has been studied for use in PMOS. Inositol is a metabolite naturally made in the body but production of this metabolite is shifted in PMOS. Foods such as nuts and seeds as well as legumes contain inositol. The forms specifically found to be beneficial are myo-Inositol and d-chiro-inositol at a ratio 40:1 favoring myo-inositol improves insulin signaling and reduces androgen production in PMOS. This is safe and effective and can be used as part of the treatment plan for PMOS. Doses utilized tend to be 1000-4000 mg daily.
Vitamin D
Optimal levels of vitamin D in the body is important for glucose regulation and metabolic health in general. There is also evidence to support adequate levels are important for ovarian function as well. Vitamin D deficient PCOS women were less likely to ovulate compared to those with levels over 20 ng/mL which quite frankly is not optimal by most functional medicine standards. Supplementation of vitamin D orally at doses 1000-5000 IU depending on levels to achieve levels of 50-60 ng/mL is recommended in the setting of PMOS. It should be noted that one can take “too much” vitamin D as it is fat soluble and will bioaccumulate which is why testing can be helpful.
Omega 3 Fatty Acids
Optimizing omega 3 index (the percentage of omega 3 in the body’s cell membranes) supports insulin sensitivity and reduces inflammation which are key features of PMOS. It makes sense to be either eating foods that have omega 3 fats or supplementing when those foods are lacking to optimize hormone health. Omega 3 supplementation in women with PMOS reduced inflammatory markers such as C-Reactive Protein as well as reduced testosterone and Luteinizing hormone all of which are often high in this condition. Foods high in omega 3 tend to be cold water fish such as salmon, sardines and anchovy as well as plant based sources such as flax seeds, chia seeds and walnuts. A typical supplemental dose of omega-3 fatty acids is around 1000 – 2000 mg daily.
Other Insulin Sensitizing Botanicals and Nutrients
In the functional medicine model we often use insulin sensitizers in the setting of insulin resistance. Examples of insulin sensitizers are berberine, alpha lipoic acid, cinnamon and chromium. Often these sorts of ingredients are combined in various doses with the goal of improving insulin sensitivity in combination with lifestyle changes as outlined above.
Detoxification Support
It is often helpful to look at supporting detoxification pathways in PMOS given the endocrine disrupting toxicant exposure in the modern world. We certainly can take an “assumption approach” but there is availability of advanced testing to further clarify exposures. In addition we can support the liver’s ability to make these exposures water soluble to eliminate them while looking at our household products and minimizing incoming toxic burden.
Specifically, choosing products that do not have Triclosan or Parabens is very relevant to PMOS. It can be as simple as reading a label and swapping out a product such as toothpaste or soap.
Eating foods that support hormone detoxification pathways such as cruciferous vegetables can also be very helpful in the setting of PMOS. We think about not just the increased production of the hormone but also the efficiency of elimination of excess hormone.
Sometimes it is helpful to have genetic testing that looks at “efficiency” of our detox pathways as this is variable. For example, some people have a genetic variant that makes them less efficient at making an important detoxification antioxidant called glutathione. If we are aware of that vulnerability we can intervene to support that pathway. There are also genetic
References:
Thomas G Gulliams PhD. The Standard Monograph Series PCOS Volume 20 No. 2
Talebi S, Zeraattalab-Motlagh S, Jalilpiran Y, Payandeh N, Ansari S, Mohammadi H, Djafarian K, Ranjbar M, Sadeghi S, Taghizadeh M and Shab-Bidar S (2023) The effects of pro-, pre-, and synbiotics supplementation on polycystic ovary syndrome: an umbrella review of meta-analyses of randomized controlled trials. Front. Nutr. 10:1178842. doi: 10.3389/fnut.2023.1178842
Srnovršnik T, Virant-Klun I, Pinter B. Polycystic Ovary Syndrome and Endocrine Disruptors (Bisphenols, Parabens, and Triclosan)-A Systematic Review. Life (Basel). 2023 Jan 4;13(1):138. doi: 10.3390/life13010138. PMID: 36676087; PMCID: PMC9864804.
