What could be contributing to your PCOS? And why you need to know.

By Clare Goodwin

Last updated: December 17, 2021

Many women forget to ask the most important question regarding their PCOS: ‘What is the cause of PCOS?’ I often see comments on Facebook or Reddit from people asking questions such as, ‘What is the best diet for PCOS?’ or ‘What supplements should I take for PCOS?’ This is completely understandable and natural, but it’s kind of like asking, ‘What type of fuel should I put in my car?’ The answer is, “It depends on what type of car you have.”

In terms of PCOS, the answers to all of those questions depend on the type of PCOS you have or, more accurately, your personal cause of PCOS. PCOS is a syndrome with a few common elements, but the cause of those, and therefore the treatment, differ for every woman.

I worked with three really interesting clients with PCOS, ‘Kat,’ ‘Sarah,’ and ‘Megan’. They all came to me with the problem of being unable to get pregnant, but that’s where the similarities stopped. Had I treated them all in the same way then I would have most likely made their PCOS worse.

Kat was diagnosed with PCOS after she failed to get pregnant. She experienced:

• Normal periods before going on the pill, aged 21.
• Periods didn’t return when she came off it.
• No other typical symptoms of PCOS.

Sarah had always struggled with her weight:

• Weight gain of 3-4kg each year, starting at high school.
• Diagnosed with PCOS and insulin resistance.
• Subsequently told to lose weight if she wanted to get pregnant.
• Could never successfully maintain any weight loss.

Megan was a city lawyer:

• Always a normal weight, with no period issues.
• Began exercising to ‘lean up’ before her wedding.
• Happy with initial results, then began to put weight on and it wouldn’t budge.
• Noticed changes to periods when she came off the pill to try and get pregnant.
• Gynaecologist diagnosed her with PCOS after she tried for a year to get pregnant.

All of the women that I’ve provided details about have PCOS, but they all presented with different symptoms. For me to know how to help those women, I needed to know their own individual cause of PCOS. But first, let’s look at what PCOS actually is.

What is Polycystic Ovarian Syndrome?

PCOS is a condition where a woman doesn’t ovulate because the body is producing excess androgens.  Androgens are a group of hormones that include testosterone, as well as DHEA-S and androstenedione. They are responsible for most PCOS symptoms, including infertility, acne, hirsutism, and male pattern balding. According to the Androgen Excess and PCOS Society Taskforce guidelines, PCOS should be diagnosed by a blood test to test your androgen levels, the presence of polycystic ovaries (or lack of ovulation).

Even a minor amount of excess androgens can stop normal menstruation and ovulation. But the great news is that it’s totally possible to reduce these levels and begin ovulating again. The secret is to treat what’s androgen levels to be high in the first place.

What causes PCOS?

Contrary to the name, cysts do not cause PCOS. Cysts are simply a symptom of the metabolic and hormonal storm that’s going on in the body. The cysts are egg follicles that were not released when ovulation was meant to occur. Rather than being released, they remain ‘stuck’ on the ovary and appear as cysts.

Up to 25% of ‘normal’ woman have poly (many) cystic ovaries. However, to have PCOS you also need to have the high levels of androgens. Therefore, when we talk about the cause of PCOS, what we are actually taking about is the cause of the high androgen levels.

There is a genetic component to developing high androgens and PCOS. However, these genes can be turned on and off by environmental factors. This is called epigenetics. Individuals with PCOS genes become more susceptible to developing the condition when the right environmental factors are present. This means that if we remove these environmental factors, i.e. treat the root cause of PCOS, then PCOS symptoms can be reversed.

The secret is finding which factors are affecting you.

This article will outline the top causes of high androgens.

The most common causes of PCOS

PCOS and insulin resistance and inflammation

Inflammation and insulin resistance are the biggest contributors to PCOS. Sarah, who I mentioned above, was a classic example of this. Studies show that 70% of women with PCOS have insulin resistance.

Insulin is our storage hormone. When we eat, our body detects a rise in blood sugar. When blood sugar is high for prolonged periods of time, our body doesn’t like it. This is because it can lead to damage in the cells of our brain, liver, pancreas, heart, and eyes. Therefore, the body stores excess blood sugar in muscle and liver cells for later use.

Insulin is the hormone that tells the cells to open up and let glucose in. It’s excreted by the pancreas and binds to a receptor on the cell. This works in a similar way to a key opening a door. When the key has been used too much, or there is chronic low grade inflammation, the lock starts to get a bit worn and clogged up. The key no longer fits. This is insulin resistance.

Why is high insulin bad?

High insulin levels stimulate the ovaries to produce more androgens. They also reduce the amount of Sex Hormone Binding Globulin (SHBG) in the blood. SHBG is like a sponge for excess hormones. If levels of it are low then the levels of hormones in the blood will be much higher.

Not all women with high insulin develop excess androgens and/or PCOS. This is the reason that scientists propose that genes play a role.

You may have heard about insulin resistance. But you probably haven’t been told about its connection to inflammation. Inflammation occurs when your immune system is chronically activated. Studies have now shown that inflammation can cause insulin resistance. It may also have to be present for insulin resistance to occur in the first place. This is an important consideration when deciding on the best course of treatment for PCOS. It’s also the reason why simply removing carbs isn’t an effective treatment for many women. The inflammation must also be treated.

‘Post-Pill’ PCOS

‘Post-pill PCOS’ is a term coined by Dr Lara Briden. Briden is an amazing naturopathic doctor, hormone health advocate, and author of the Period Repair Manual. According to her, ‘Post-pill PCOS is the second most common type of PCOS. This is something that I agree with. Kat is the perfect example of somebody with post-pill PCOS.

The pill disrupts communication between the brain and ovaries, thus stopping ovulation. For most women this communication returns to normal after they stop taking the pill, and their periods and ovulation resume. But for some women, it doesn’t. In these cases, it’s not the androgens causing problems, but the ratio of Luteinizing Hormone (LH) and Follicle Stimulating Hormone (FSH). LH and FSH are the hormones which kick-start ovulation. If the ratio of LH to FSH become greater than 3:1 then ovulation doesn’t occur.

Post-pill PCOS isn’t a well recognised form of PCOS. As a result, there’s very little information available about it. If, like Kat, you had normal periods before going on the pill and don’t present any other PCOS symptoms, then it’s likely that you have post-pill PCOS.

Stress-based PCOS

Stress-based, or ‘adrenal’, PCOS is the third most common cause of PCOS that I see. Megan was an example of this. ‘Stress’ relates to both physical stress, e.g. too much high intensity exercise, or psychological stress. Frequently, as was the case with Megan, it’s a combination of the two, such as a highly stressful job and too much high intensity exercise.

When we put ourselves under a lot of stress, the brain stimulates the adrenal glands to produce stress hormones. These hormones are adrenaline (the ‘fight-or-flight’ hormone) and cortisol, adrenaline’s long-term cousin. At the same time however, the brain also produces androgens, such as DHEA-S and androstenedione. Most people, even some physicians, are not aware that 50% of women with PCOS have excess adrenal androgens.

The following could be an indication that stress hormones are causing or contributing to your PCOS:

• Feeling tired all the time.
• Waking up tired, even after 7-8 hours sleep.
• Feeling exhausted after exercise.
• Feeling tired, but wired, at night.

Inflammation (non-insulin resistant)

When your immune system is chronically activated, inflammation occurs. As I mentioned above, it often goes hand in hand with insulin resistance, but it can also act alone. Many things can cause inflammation, including:

• Eating foods that you’re intolerant to.
• Poor gut health.
• High stress hormones (yes, it goes hand in hand with stress PCOS too!).
• Environmental toxins

Inflammation has been shown to increase androgens and stop ovulation, even without insulin resistance. If you get recurrent infections or are sick all the time then this could be an indicator that you have chronic inflammation. Other signs includes allergies, asthma, sore joints, irritable bowel syndrome, or skin problems like eczema.

Hidden cause or contributor

So you’ve read through the four sections above, but nothing is jumping out at you as being your cause of PCOS. If so, you may have a ‘hidden’ cause of PCOS, instead. A thyroid condition is the one that I see most often. Given that up to a quarter of women with PCOS have a thyroid condition, this isn’t surprising. Unfortunately, many women never have their thyroid markers tested. Even if they do, it’s usually only Thyroid Stimulating Hormone (TSH) that’s measured.

TSH should be a good indicator that there is something wrong with your thyroid. Unfortunately, this isn’t always the case. It’s been shown that the range deemed ‘normal’ is far too high. Studies show that it should be 2.5mIU/L, but it’s currently set at 4mIU/L. Inflammation may also have an effect on TSH levels, making them appear normal even when they’re not. Stress has been shown to have a similar effect. Given that inflammation and stress have both been found to be a cause of PCOS, you can see that a thyroid condition could also be a cause of PCOS.

High cholesterol and hair loss are both symptoms of a thyroid condition. Hair loss is also a symptom of PCOS, so it can be missed as one for a thyroid. Please get your thyroid tested if you’re suffering from high cholesterol or hair loss.

Your cause of PCOS: you don’t need to fit in just one group

You may have read this and thought that you fit into a couple of boxes. This is quite normal, especially in my clients who are corporate professionals. Working long, stress-filled hours with tight deadlines, exercising daily to try to keep your weight in check. Adrenal hormones can exacerbate what may start as insulin resistance and inflammation.

Years ago, I was in a similar position. At the time, I was completing a dual honours degree whilst training for World Triathlon championships. I was training twice a day, living on sports drinks and gels (hello insulin resistance!), and feeling absolutely shattered. As a child, I regularly had tonsillitis. That meant that I had 20 rounds of antibiotics before I was 10 years old. This caused me to have a host of gut problems and chronic inflammation. Unsurprisingly, my tests results showed:

• Insulin resistance.
• High inflammatory markers.
• High DHEA-S and cortisol that was three times the normal range.
• A possible thyroid condition. This wasn’t picked up until much later. Rather than being a cause of my PCOS, I believe that it was caused by inflammation and high stress hormones.

I significantly reduced my carb intake after I was diagnosed with insulin resistance. However, it wasn’t until I addressed the inflammation, stopped all endurance exercise, fixed my gut health and stress hormone levels that I started to see any improvements in my PCOS. The point that I’m trying to make here is don’t try and squeeze yourself into one box. Instead, get as many blood tests as possible to try to determine all possible factors that could be your unique cause of PCOS.

What PCOS symptom tests should I get?

Now that you understand all of the different causes, you’re probably wondering how you can find out your own cause of PCOS. Symptoms are a good indicator of PCOS. However, a blood test is necessary to be absolutely sure. You should try to get everything tested to make sure that nothing is missed out.