Struggling to conceive? You could have PCOS, a common fertility problem ... and tweaks to your diet could help
Hormones and fertility are linked, so nutrition is vitally important, explains dietitian Orla Walsh
A s a dietitian it's incredibly frustrating how little attention is given to nutrition in the pursuit of fertility. Fertility and all our hormones are interlinked. Your diet can help improve metabolic and reproductive health. After all, food feeds not just you as a whole but every single system within the body. You need to provide each system with the appropriate food to ensure it's fuelled optimally.
Polycystic ovary syndrome (PCOS) is incredibly common - it's thought that about one in five women has polycystic ovaries and approximately one in 10 has PCOS to some degree. Despite affecting so many, PCOS is regularly overlooked and left undertreated. Those that are diagnosed will not always receive all the treatment they require.
So what is PCOS?
The ovaries are glands that are found beside a woman's womb. They make eggs and various hormones. The main hormones that are made in the ovaries are oestrogen and progestogen, which are known as the female hormones. The ovaries also produce small amounts of so-called male hormones called androgens such as testosterone. PCOS can impact the balance of hormones that are made within the ovaries. For example, the ovaries may make more testosterone than they should. This can cause some of them symptoms associated with PCOS.
During the menstrual cycle, an egg develops within a little follicle in the ovary. The release of an egg from the ovary normally occurs once a month, resulting in pregnancy or a period two weeks later. In PCOS, lots of little follicles can develop which may interfere with or prevent ovulation. On ultrasound this gives the appearance of small cysts, which look like a string of pearls on the ovaries. When a woman doesn't ovulate, this can offset her menstrual cycle and make it more challenging to conceive. The good news is that the menstrual cycle of women with PCOS often improves as they get older. Additionally, their reproductive life span can extend beyond that of women without PCOS because of their higher adrenal and ovarian androgen levels.
Symptoms associated with PCOS are often due to the hormone imbalance and include the likes of excessive hair growth on the face and body, hair loss on the top of the head, acne and skin problems, as well as irregular or absent periods. Other symptoms which may be part of the cause as well as a result of PCOS include weight gain on the waist, difficulty losing weight and intense cravings for carbohydrates.
PCOS is often a result of hormonal imbalance which may be exacerbated or caused by being overweight and obese. This is due in part to insulin resistance caused by excess body fat. A significant part of treatment for some women is weight loss.
However, women who are a healthy weight can also develop PCOS. In all women with PCOS, dietary manipulation and supplements are required to optimise treatment. Although many women seek help with their PCOS due to the fertility issues it can cause, all women need to adjust their lifestyle due to the increased risk of type 2 diabetes and heart disease.
There are many ways to improve fertility and symptoms in women with PCOS. Eating breakfast like a king and decreasing your calorie intake as the day moves on can have significant benefits.
In one study, 60 women with a healthy BMI who had PCOS were randomised into two groups, both of which ate the same amount of calories per day (1,800 kcal).
However, the two groups had different distributions of calories. A 980kcal breakfast, 640 kcal lunch and 190 kcal dinner or a 190 kcal breakfast, 640 kcal lunch and 980 kcal dinner. They ate this way for 90 days.
Those in the 'big breakfast' group experienced a 56% decrease in insulin resistance and a 50% decrease in testosterone. This reduction of insulin and testosterone levels led to a 50% rise in ovulation rate, indicated by a rise in progesterone, by the end of the study.
Another approach involves modifying the glycemic index (GI) of the carbohydrates eaten to minimise the rise in insulin and glucose after meals. Scientists compared the effects of a low-GI diet versus a regular diet in 96 women with PCOS for 12 months.
Nearly all of the women following the low-GI diet had regular periods (95% versus 63% on a regular diet). What's also important to note from this study is that despite not following a calorie-restricted plan, the women with high insulin levels at the start of the study experienced a twofold greater reduction in body fat following the low GI diet.
Lower carb, higher protein
When someone follows a lower carbohydrate and higher protein diet they are following a low glycaemic load (GL) plan. A low GL plan is a common nutrition strategy for PCOS. A study in The American Journal of Clinical Nutrition showed a higher protein diet (greater than 40% of calories from protein) without caloric restriction resulted in greater weight loss (17lb versus 7lb) despite not actively reducing calories. The women following this plan also lost more inches of their waist and had a greater decrease in blood sugar levels.
A study published in The Journal of Clinical Endocrinology & Metabolism showed that postmenopausal women with PCOS had greater inflammation than women without PCOS. This was measured by checking their blood for C-reactive protein (CRP) levels. The level of this inflammatory marker was seen to worsen with age.
In 2015 researchers investigated the effects of an anti-inflammatory diet in women with PCOS. One hundred overweight women with PCOS ate a calorie-reduced diet that consisted of five small meals with 25% proteins, 25% fat and 50% carbohydrates for three months. The diet was high in fibre and anti-inflammatory foods such as fish, legumes, green tea and low fat dairy.
Foods like chicken, red meat and added sugars were reduced. The average weight loss after 12 weeks was 7% and the women experienced significant reductions in cholesterol, blood pressure and fasting blood sugar levels.
Additionally, levels of CRP were reduced by one-third, and two-thirds of the women regained their regular menstrual cycle.
A similar study tested this diet too, but used The DASH diet (Dietary Approaches to Stop Hypertension), naturally rich in antioxidants. The DASH diet resulted in significant reductions in insulin and CRP levels within eight weeks, as well as inches lost off the participant's waist.
Supplements to discuss with your dietitian
Inositol -Inositols are found in foods such as fruits, beans, cereals, and buckwheat. Both myo-inositol (MYO) and D-chiro-inositol (DCI) are well studied and often advised in women with PCOS. They help regulate the activity of certain hormones. MYO has been shown to improve insulin sensitivity as well as egg quality and ovulation. Other research showed that a combination of MYO and DCI is even better at improving hormone and metabolic balance.
Cinnamon - Eating one to six grammes of cinnamon daily has been shown to significantly decrease fasting blood sugars and improve cholesterol profile. This may help women who have PCOS to protect their body from diabetes and heart disease.
Alpha-lipoic acid - Alpha-lipoic acid (ALA) is a naturally occurring antioxidant which is thought to sensitise our body to insulin. A systematic review which included 12 trials showed that supplementation with ALA slightly but significantly decreased body weight and BMI. In women with PCOS, 16 weeks of supplementation showed a 13.5% improvement in insulin sensitivity and improvements in certain cholesterol levels.
Omega-3 fatty acids - A study gave overweight women with PCOS omega-3 fatty acid supplements daily for six months. BMI, insulin and testosterone levels decreased significantly during treatment. In a different study, an omega-3 supplement was found to regulate periods and significantly lower testosterone in both overweight and lean women with PCOS.
N-Acetylcysteine - N-acetylcysteine (NAC) is an antioxidant and amino acid. It is involved in fighting oxidative stress and inflammation. A systemic review from 2015 which included eight studies and 910 women with PCOS reported that women taking a supplement have better odds of ovulating and getting pregnant.
Dangers of diabetes
As PCOS is hormonal, it's a no-brainer that someone's PCOS would change over time. Fortunately, there have been studies examining the changes in the presentation of PCOS with age. On the plus side, older women with PCOS may have fewer hot flushes compared with women without PCOS. Unfortunately, they have been shown to have more issues with body and facial hair (64% versus 9%).
Nevertheless, the biggest takeaway point here is that PCOS is not just a reproductive disorder. According to one estimate, by age 40, nearly 50% of women with PCOS will develop prediabetes or type 2 diabetes.
A different study showed that type 2 diabetes was nearly seven times higher in middle-aged women with PCOS than women of the same age who do not have PCOS. Your diet and lifestyle therefore need to be tailored to lowering your risk of diabetes. Due to a possibly more rapid progression from impaired glucose tolerance to type 2 diabetes, women with PCOS require regular screening.
Heart disease is also an issue. Cholesterol levels worsen as women with PCOS age, especially with regard to triglyceride and HDL concentrations. This brings more importance to oily fish, lower sugar intake and high intensity training.
Although the diagnosis is not something that any woman wants to hear, the good news is that tailored nutritional intervention can make one hell of a difference.