Polycystic Ovary Syndrome (PCOS) is one of the most common — and most misunderstood — hormonal conditions in the Western world, and the leading cause of infertility in women in the U.S.1
Historically a PCOS diagnosis is based on certain criteria that approach the condition from a very black-and-white perspective.2 Either you have it or you don’t.
Unfortunately, our current classification of the condition delays diagnosis and treatment for many women, who often experience some aspects of the condition but not others.
Hormonal disruptions including elevated luteinizing hormone (LH), elevated testosterone (or other androgens like androstenedione, DHT or DHEA-S), elevated prolactin, abnormal cortisol levels, low progesterone, low estrogen, estrogen dominance, and insulin resistance (ranging from mild to severe) can all be present.
Symptoms of PCOS may include:
Some women have all of these symptoms, while others have only a few. Some women get a period, while others do not. Some women struggle to get pregnant, while others have little issue here. Some women have clear, healthy skin, while others regularly deal with breakouts and rogue hairs. Some women are overweight or struggle to lose body fat, while others do not.
There is no one-size-fits-all when it comes to PCOS symptoms, so why should nutrition for a woman with PCOS be approached that way?
The nuances and varying types of PCOS are many, and this article would turn into a book if I tried to cover them all here. Because one of the most common concerns for women with PCOS is difficulty with weight loss, in this article I will focus on that as well as nutrition specific to this condition.
A hallmark of PCOS is blood sugar control and insulin resistance, but with varying severity. Insulin resistance occurs when your cells do not immediately heed insulin’s message. This creates prolonged blood sugar elevations and excess insulin secretion, and can result in rebound low blood sugar after insulin’s signal finally gets through.
A common mistake among women with PCOS is making the assumption that if they don’t “look the part” — meaning they are struggling with weight loss, have a mustache, and no period — then they do not have insulin resistance or blood sugar problems.
Sadly, many doctors may say, “Well, you just don’t look like you have PCOS, so we’re not testing any further.” Coaches and trainers may say, “What do you mean you don’t tolerate all these carbs I’m telling you to eat for your training? You don’t look like you can possibly have insulin resistance.”
The thing is you can’t tell someone’s insulin response by looking at them. Just like someone who is overweight can have normal hormone and insulin responses upon testing, someone without a lot of excess weight can have insulin resistance. Because of this, PCOS nutrition advice has to be more nuanced. It’s not as simple as going low carb or eating all the carbs.
PCOS body types are typically referred to as lean type and heavy type — which I dislike, because we are conditioned to think of “heavy” as bad and “lean” as good. With PCOS, you can have insulin resistance and blood sugar problems whether you are "lean" or "heavy." Insulin resistance happens on a spectrum and varies from woman to woman (and even from tissue to tissue within the same woman).
In my opinion, it is much better to categorize the various body types with PCOS depending on how sensitive to insulin they are. I think of the “heavy” type instead as having insulin-resistant muscle tissue and insulin-sensitive fat tissue, and the opposite for "lean" type (that is, insulin resistant-fat tissue and insulin-sensitive muscle tissue). This removes the labels of good/bad/heavy/lean and illustrates where the problem lies.
With this understanding, you’re guided towards what you can do about your particular PCOS shade of grey, as well as understand why all women with PCOS don’t have the same body type.
Think of insulin sensitivity as two sides of a coin: more resistant and more compliant or sensitive. When a tissue is sensitive, it heeds insulin signaling well, and nutrients like glucose and vitamins get in. When it’s resistant, it takes a lot more insulin to get that tissue to respond to insulin and finally let nutrients in. The tissues we’re primarily talking about in the case of PCOS are the ovaries, liver, muscle, and fat.
A woman can be sensitive at one tissue but not at another — except the ovaries. They remain insulin-sensitive, which is one reason why female hormone imbalances show up for women with PCOS almost across the board, whereas other symptoms vary.
This tissue-specific insulin resistance is where the two body types we see in PCOS come into play.
Some women with PCOS have an easy time gaining weight and a hard time losing it. Others may not be overweight, but even they will say losing just a couple of pounds is incredibly difficult.
When fat cells are resistant to insulin, they don’t respond as quickly to insulin’s message to store up. Women with insulin-resistant fat cells gain body fat less easily, and because their muscles take in nutrients and glucose quickly, they often deal with low blood sugar issues as well as insulin resistance issues (higher blood sugar). These women are typically called the “lean” type, but I refer to them as the fat-resistant PCOS type.
In women with the “heavy” body type, or what I call the muscle-resistant PCOS type, it's the muscle cells that are resistant to insulin. They don’t take in nutrients as quickly, and more is stored in body fat, which is sensitive. These women tend to experience more fatigue and exercise intolerance, as well as increased body fat.
Of course, it gets a bit more complicated. The dynamic described above can change over time, and other hormone imbalances, such as with cortisol and thyroid, are also present.
Often, the muscle-resistant/fat-sensitive women deal with high cortisol problems such as inflammation, difficulty falling asleep, and anxiety. They usually do better with a low carb plan. The fat-resistant/muscle-sensitive women often have trouble with low cortisol and deal with increased sugar cravings, fatigue between meals, and difficulty staying asleep. They will not do well with a very low carb plan (although they still have to be more mindful that the average woman of their carb intake).
Thyroid issues may sometimes be the cause or result of some manifestations of PCOS. In fact, some cystic ovaries resolve completely once thyroid hormone levels are restored to proper ranges. I often say that Hashimoto’s (autoimmune hypothyroidism) and PCOS are best friends, since they so frequently show up together in the same woman (take our GGS leader, Molly Galbraith, for example). There are a couple of hypotheses on the table for why this is. One hypothesis is that some forms of PCOS appear to be autoimmune in origin.
As you can see, not only are there multiple manifestations of PCOS, there are also multiple causes. It’s no wonder why a lot of the PCOS advice out there leads to so much confusion and frustration. If you have PCOS and are struggling with weight loss, below are my best tips for improving your nutrition, stamina, and hormone balance.
This is perhaps the best advice I can give any woman wondering how to eat to manage her PCOS. While insulin resistance has a role in each type of PCOS, often, the harder it is for you to lose fat the worse your insulin resistance is (at least in the case of PCOS, though not necessarily for every woman). The less body fat you have, often the more careful you have to be about not going too low carb, but still going low enough.
This is tricky. My PCOS low-carb diet is very different from Molly’s PCOS low-carb diet, and that may be very different from your low-carb diet. For example, Molly tolerates more carbs than me, yet we both have PCOS, so “low carb” or “high carb” become relevant terms and not an absolute definition based on a specific amount of carbs. Right now, having two small children and not getting nearly enough sleep, my adrenal issues are worse than ever, and I need more carbs than I used to.
As I always say, women’s hormones are a moving target — we have to keep up. Keeping up means listening to your hormone’s signals, how they talk to you via appetite, cravings, energy, and sleep. As these symptoms change, you have to adapt your diet and know that your UCT can change. When it comes to carbs...
Note these symptoms before meals:
Sugar or starchy carb cravings
Low energy, fatigue relieved by eating
Feeling irritable, cranky or lightheaded
Note these symptoms after meals:
Low energy or sleepiness
Sugar or carb cravings (not relieved by eating these foods)
Increased hunger even after eating a balanced meal
Watch symptoms after you eat a particular amount of a particular carb (i.e. a half cup of sweet potato). Are you sleepy, craving more carbs or more food, does eating carbs or sweets not relieve that craving? If so this was too much of this type of carb for you. Eat the same meal next time with say one-third cup of sweet potato and see how you do.
On the flip side, if you find that with half a cup of sweet potato you feel fine immediately after eating, but then feel ravenously hungry, irritable, cranky, or lightheaded within one to two hours, meaning that this particular amount and type of carb didn’t work so well for you.
To clarify, I’m talking about starchy carbs and fruit when I talk about “carbs” in this post. Non-starchy veggies are a PCOS girl’s best friend. Eat them in large amounts and eat them often. If your blood sugar is running high or low, you’ll benefit from the fiber. Veggies contain phytonutrients, antioxidants, and minerals, which can run low in PCOS due to frequent urination (mineral loss) and metabolic stress (antioxidants).
Finding your UCT will require some simple experimentation with your meals. Pick one starchy or sugary fruit, and eat it with the same combo of protein, fiber and fat.
For example, eat a meal consisting of a mixed green salad dressed with olive oil and vinegar, four ounces of chicken breast, and half a cup (or about six bites) of sweet potato. Then watch for symptoms above immediately after eating or two hours after eating.
If you experience sleepiness, cravings for coffee or stimulants, or cravings for more starches or sweets right after eating, try cutting the amount of sweet potato back at the next meal of mixed greens salad and chicken.
If you experience cravings, ravenous hunger, irritability, lightheadedness, and crankiness one to two hours after eating, then at the next meal increase your protein and fiber slightly (a bit more chicken and a bit more greens). Do not adjust carbs yet. Watch for symptoms.
If this doesn’t relieve the issue, at your next meal, add a touch more healthy fat (olive oil, a few nuts, or some avocado) to the meal we’ve been using as an example. If none of these small adjustments work, then increase the sweet potato by two bites.
Continue this experiment with different types of carbs and different amounts. While it may seem tedious, most women find they get in tune with these symptoms within a couple of days and can then infer how they will feel for multiple foods based on one food reaction.
For example, I can tolerate about two bites of gluten-free grains, whether it is quinoa or brown rice. I can tolerate about that same amount of legumes. But sweet potato — although I love it — seems to make me crave more sweet potatoes no matter if I have one bite or 10. Conclusion: sweet potatoes are not an ideal carb for me per my UCT.
This can be a big issue when coaches push carbs on women who say they feel overly stuffed, fatigued, or see an increase in appetite or cravings after they eat the prescribed number of carb grams.
If you have insulin issues and are training hard, you may need more carbs than your less active counterpart, but you often can’t do as many grams in one sitting as your coach may recommend. Yes, you are always more insulin-sensitive post workout, and yes, you need to refuel. However, if you experience appetite, cravings, or energy changes from a large serving of carbs, you need to adjust that plan.
When you have PCOS, finding your UCT and sticking to it is important beyond your fat loss of performance goals. Insulin surges due to stress or high carb loads (even high protein loads for some) will upregulate aromatase (an enzyme found in fat cells) that converts testosterone to an active, more problematic estrogen (called estrone), and these insulin spikes also cause 17-lyase in the ovaries to convert progesterone to testosterone.
Both of these hormonal shifts make ovulation and a normal cycle difficult with PCOS, and the testosterone increase leads to unwanted hair growth and acne, as well as worsening insulin resistance, inflammation, increased risk of diabetes, and heart disease.
When you have insulin resistance, some minute hormonal interactions become magnified. With insulin resistance, the combination of fat and carbohydrates (especially saturated fat and carbs) becomes more of an issue for increased fat storage.
Women with PCOS are wise to side step frequent high starch and high fat (particularly saturated fat) meals. Of course, you may occasionally have some pizza, guac and chips, French fries, or even a “healthier” combo of carbs and fat, like sweet potato hash made with whole eggs and a generous serving of butter. However, if this combo is a part of your daily diet or happens frequently, it’s a variable you can adjust to get better results.
Persistent Organic Pollutants (POPS, also known as plastic and pesticide residues), and hormones in our animal products can be a bigger problem for women with PCOS, as the delicate female hormone system is already off kilter. Hormones and POPS are fat-soluble, so whatever the animal was exposed to through their water supply, diet, medical care (i.e. if the animal was given hormones), will have more of an estrogenic effect in us than someone with a normal hormone balance.
Keep in mind that grass-fed, organic, or otherwise more healthfully raised animals still have a metabolism. They will still have some estrogen in their body fat and likely some POPS due to our modern environment and water supply; it’s simply hard to escape this entirely—even for blissful, pasture-raised cattle.
Again, this isn’t a huge issue for every woman, but if you have hormone trouble, things like this can tip the scales further out of balance, and your health and metabolism may fare better if you’re mindful here.
Remember this: it may not be just one thing, like POPS or non-grass-fed beef getting in the way of you feeling better or making more progress. If you add this to several other metabolic stressors (i.e. Hashimoto’s, a food intolerance, or adrenal issues), together they can easily add up to more metabolic stress and make it harder to maintain your health and your physique.
If you have a hormonal issue like PCOS or Hashimoto’s, or are going through menopause, general advice falls very short for you, largely because of these complex hormonal, nutritional, and environmental interactions.
Dogmatically taking a stand on issues like this as "good" or "bad," hope or hype, black or white, will only keep you from feeling and looking your best. Sadly, this is something I see all over fitness and health blogs. The truth is that things like this (or say, gluten for example), may be no biggie for most people, but they are a very big problem for some (beyond those with Celiac). Or, it may be a “minor” issue, but if you also have four other “minor” issues, they’re compounding and create a much bigger challenge.
One potential nutritional variable can really hinder health and weight loss success is inflammation from food sensitivities.
The complex interaction of hormones, food, and inflammation simply cannot be ignored. Food sensitivities are not the hives or throat-tightening reactions that you associate with someone having a peanut or strawberry allergy. Sensitivities are more low-grade, non-life-threatening immune reactions that many of us deal with due to a variety of factors.
You’ve probably heard a bit about the most frequent offenders: gluten, dairy, and soy. However, you can be sensitive to almost anything—and it may not always show up as a tummy ache. Headaches, skin issues, depression, anxiety, and fatigue can all be manifestations of food intolerances.
To figure out if you have low-grade inflammation from food sensitivities you can get tested (the only lab I recommend is Cyrex), or you can do a trial elimination of these foods and see if you do better. This issue is not unique to PCOS, but when you already have a metabolic Achilles heel like insulin resistance, slight food intolerances will be harder for you to deal with.
For the most part, yes. For some of you, though, it’s tricky. Beyond carbs and fat content (as discussed earlier), the total amount of protein can be an issue for some women with PCOS.
Too much protein? What the what?
Choosing protein instead of carbs is wise in general for women with PCOS, For example, a burger without the bun, or a big salad with fish or chicken when dining at a restaurant.
Protein is often thought of as the “do no harm” macro with PCOS, leaving carbs to take all the heat. However, protein still causes an insulin release, but it also causes a glucagon release. The rise in insulin and blood sugar are not nearly as steep with protein as they are with carbs, so it is where the bulk of macros should come from (about 40 percent of total daily calories) for most women with PCOS.
Many women feel very satisfied with protein and don’t overdo it the way they might with carbs (though it can be done).
If you experience an increase in appetite, fatigue, or cravings after a big serving of protein you may have to back down and increase the veggies to see if that solves the issue. You may also have to add a touch more fat to your meal to get your ideal metabolic mix. Try adding one additional serving of fat to your meal such as one-fourth of an avocado, one tablespoon of butter or coconut oil, or a fattier cut of red meat.
When it comes to protein, fat content matters for the reasons I mentioned above (POPS). Avoid fattier meats as a daily staple. While it’s fine to eat them a few times per week, the ideal choices for the bulk of your diet should be lean meats like chicken or turkey, lean grass-fed beef or bison, and fish. When cooking eggs (scrambled eggs or omelets, for example), use only one or two yolks and bolster with extra whites.
Stress of all types will impact women with PCOS more profoundly than their insulin-sensitive, hormonally balanced girlfriends. Stress will often make blood sugar issues worse (whether high or low), compound fat loss challenges, and play into the complex web of thyroid, insulin and cortisol problems often found in PCOS.
Common sense says you should “try to watch your stress.” Still, many of us are overdoing it in the gym and in life. Make it a point to make more time for recovery, get more sleep, avoid over-training, and avoid food stressors like sensitivities, skipping meals, and overeating.
All too often, stress management is the only variable that needs to change with a woman’s plan. Months of fussing over macros and calories will have little impact if this is the case.
It’s also the one thing we rail against. “But I have to!” has become the battle cry of the modern busy woman, myself included. I know you have a big, busy life but take time to really look at your obligations and see what you can let go. And by all means, if you’re feeling taxed, drop something as you take on something new. I think here at GGS we’ve hammered into your head that “killing it” at the gym day after day is not only counter-productive to your goals, it’s a huge source of stress.
First and foremost, get that thyroid checked! There are a lot of women with PCOS who test positive for Hashimoto’s, so even when you have normal thyroid hormone levels, it’s still advisable to get tested for both, TPO and TG antibodies, as they can be positive for many years before thyroid levels become affected.
Other hormones that can be amiss with PCOS include testosterone and the other androgens such as DHEA-S, androstenedione, and d-hydro testosterone (DHT). Prolactin is often elevated with PCOS. Cortisol is worth looking into as well, as it is the other side of the blood sugar equation.
Vitamin D is another important player in PCOS because it is key in inflammation and immune regulation, and has an impact on blood sugar and insulin. This test has become very common but in case you haven’t had it checked the test to get is 25 OH vitamin D. I recommend levels between 50 and 80 ng/mL.
B12 and B6 deficiencies are common in PCOS in general and are often exaggerated when a woman is taking the Pill or Metformin, which are both incredibly common among women with PCOS. A good quality multivitamin often covers the spread, but depending on lab work, increased doses may be necessary. I recommend getting a CBC, TIBC, and checking ferritin and homocysteine levels to assess issues with these vitamins.
Finally, as this is at least in part, a blood sugar issue, regular markers of blood sugar control (beyond fasting glucose) are paramount, but often don’t get done. Hemoglobin A1C or fructosamine are great markers of blood sugar control as is home glucose monitoring. It’s rarely recommended unless a woman is diabetic, but it can be an incredibly insightful tool in customizing your diet.
As you can see now this condition has many, many shades of grey, and the common black and white approach with meds and nutrition often falls short for so many women—especially when it comes to weight loss. Because insulin has a root in most hormonal imbalances for PCOS, dialing in your UCT and adjusting your nutrition is a good start. This will help you start normalizing your entire hormonal system while you work with a provider to get adequate testing and explore other possible problems.
The good news is that this condition is profoundly impacted by the right nutrition plan. This also means that it’s not resolved by one magic pill or supplement, or simply going low carb. I hope this article arms you with information to get you well on your way to better hormone balance and helps you get in control of your PCOS.
Note from GGS: As always, please make sure you discuss any changes in your nutrition program with your doctor, registered dietitian, or other licensed healthcare provider.
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