With everything happening in the world now, understanding your body as someone with PCOS is more important than ever.
I’ll be honest, I worry about the implications that recent political decisions will have for our community.
Of all the folks most likely to find themselves with an unexpected pregnancy, its those with irregular cycles and PCOS who are one of the more at risk groups. In addition, those with PCOS often need hormonal birth control, or measures like an IUD to both help bring regularity to their cycles and to prevent (or in some cases treat) the more rare, but very real complications of endometrial cancer.
From a fertility perspective, those with PCOS are some of the most likely to need assisted reproductive assistance in the form of IVF, a measure at risk for being outlawed in some communities. I am hopeful that common sense will prevail and that these medically necessary treatments will continue to be available to those of us with PCOS, but I also believe in being prepared.
Knowledge IS power and understanding your body and how it works as a biologically female person is one of the greatest ways you can have control over your own body.
I recently uploaded an old series I did on the cycles in PCOS, what goes wrong, etc on my Youtube channel. For a deeper perspective on this, I’d highly recommend heading over there.
My course, Functional PCOS also has modules on fertility, cycle tracking and the use of vitex, all to help regulate your cycle. One of the most beneficial things you can do to have a more predictable cycle in PCOS is address the root causes. All of this is covered in depth in the course.
So let’s talk a bit about cycles in PCOS, how they work, what tends to go wrong, and what can be done to help.
The typical menstrual cycle lasts between 28-35 days. Day one is the first day of the period.
The first two weeks are called the follicular phase, this is when your body is building up to ovulation. A hormone called follicle stimulating hormone, along with estrogen does most of this. As the weeks continue, the body selects one follicle that is more healthy than the others and begins to place it’s focus on growing that one follicle. We call this the dominant follicle.
When the follicles are growing, they are producing estrogen. The larger that dominant follicle is, the more estrogen is produced and this sends a signal to the body that it is time to ovulate.
Your body releases a hormone called Luteinizing hormone, or LH, about 24 hours before you actually ovulate. This hormone surges in and tells the ovary to release the follicle.
The follicle then travels down the fallopian tubes towards the uterus where at some point it might get fertilized if there are sperm present and become an embryo.
Typically, that process can happen with sperm that was present anywhere from a day before to five days after ovulation, but typically it happens within those first couple days around ovulation.
Once the embryo reaches the uterus, it may or may not implant into the uterine lining. The whole time it was travelling, usually about a week, the corpus luteum (the empty place on the ovary where it was originally growing) is producing progesterone which makes the uterine lining comfy and cushiony.
The embryo now has the chance to implant and if it doesn’t, it will be shed, along with the uterine lining at the end of the month.
The hormone balance is a delicate dance and when anything is thrown off, it tends to throw other things out of whack. There are several things that tend to go wrong in the PCOS cycle that can affect ovulation or implantation.
First, and typically most important, is that ovulation is often irregular or absent in PCOS due to the impact of high testosterone and insulin levels.
Higher levels of androgens in the body signal to the ovary to produce more follicles and stunt their growth. What ends up happening is a lot of hormone activity going into a large number of follicles, rather than any one follicle becoming dominant.
This is driven, in part, by the fact that many with PCOS also have a high LH to FSH ratio. There is a lot more LH in relation to FSH which confuses the body, when it is time to ovulate, it can’t hear the signal because so much LH was always floating around. There is no surge at ovulation time and this prevents ovulation.
High androgens, high LH, and most PCOS issues are driven in large part by excess insulin in the blood, called hyperinsulinemia or insulin resistance. Many with PCOS have this issue but don’t realize it because the typical labs to catch blood sugar issues are not testing the right thing. Ask your doctor to run a fasting insulin test and you may see more evidence of this problem.
If there is no ovulation, then progesterone does not get produced because there is no corpus luteum. If there’s no progesterone production, the body doesn’t get the signal to shed the uterine lining and this is why there are irregular cycles in many with PCOS.
Now, some with PCOS do have normal or semi normal, regular cycles. Maybe they are slightly irregular but come about once a month. In these folks, ovulation does tend to be occurring, it’s just that insulin levels can delay it a bit. Working on the same underlying causes will likely help regulate the cycle.
After the ovulation point, there are still some issues that affect the PCOS cycle. For example, there tends to be lower than normal levels of progesterone in relation to estrogen in PCOS. Often this doesn’t show up on lab work either because there are many different types of estrogen. However, when we look at progesterone labs about 10 days after ovulation, we tend to see the highest amount of progesterone produced and this level tends to be a bit low with PCOS.
Chronic inflammation can lower progesterone production and this can then affect how regularly we ovulate later. It can also mean that our uterine lining isn’t properly prepared for implantation, so even if we ovulated, the lining health might not be good enough for an embryo to implant and grow.
This happens often in PCOS, especially if there has been a lot of unopposed estrogen in the system which has led to something called hyperplasia, a thickened uterine lining. This is why it is so important to have a monthly period.
In addition, lower levels of progesterone can lead to polyp or fibroid development which also make the womb inhospitable or more difficult for embryos to latch.
Finally, if pregnancy does occur, those with PCOS are at higher risk of early miscarriage, typically due in part to irregular swings in blood sugar or low egg quality.
I don’t write all of this to depress you, but only to show you the whole picture. Many of those I work with are incredibly confused on why their cycles are so irregular, or why they can’t seem to get and stay pregnant when they really want to. It’s a complicated issue that requires a more root cause response. Birth control and fertility meds might help in some cases, but they aren’t addressing the original reasons for these issues.
However, there is a lot that can be done.
My first steps to regulating the cycle in PCOS always start this way.
I have a quiz here that I made to help show you some of my thought processes on how I decide what root cause is the most at the forefront. In PCOS, I’m looking at gut health/inflammation, insulin resistance, and adrenal dysfunction as the most common issues.
Depending on which one is at the forefront, my goals might be a moderately low carb, high protein, high fiber diet (in the case of insulin resistance), a comprehensive elimination diet (inflammation/gut health), or lifestyle changes like quality sleep and dedicated stress relief and regular meal times (adrenal issues). This is a huge oversimplification (my course goes into a lot more depth) but hopefully it gives you an idea of where to start. If you have more than one of these issues, which is common, you might need to combine them.
For example, a person with insulin resistance and inflammation might do best on a lower carb, high protein, high fiber diet that has an elimination component (removing the most common allergens) for the first month to three months.
I can’t tell you how many people I’ve seen regulate their cycle or get pregnant just from that combination.
By the way, a low carb diet is anything under 125g a day, I never recommend keto for PCOS unless in very specific circumstances.
My article on the ideal day for PCOS might help you more. The Ideal PCOS Day- How to Plan Your PCOS Diet like a Nutritionist
If your cycles regulate from just this, that’s wonderful! Sometimes we do need a little more support.
I’ve had many clients who could get their cycles closer together like this but still irregular. In those cases I often use vitex after a few months to help regulate them further.
Vitex (or chaste tree berry) is an herb that can help balance cycles. I do recommend working with a professional on this because it can be misused. If you can’t find someone who knows how to help you, Functional PCOS has a module on how to use vitex in a cyclical way to support regular ovulation.
You may also need other supplements to help you, like these ones which are my favorites for PCOS or the addition of some PCOS superfoods to help regulate your cycles.(9 Superfoods for PCOS ) All of this is hard work and you shouldn’t expect changes in a week or even a month, but steady consistency will get you where you want to go with time.
Tracking the cycle in PCOS is especially important for understanding your trends.
There are many great apps that can help you do this or you can use a bracelet like the Tempdrop. You can also just use a basal body temperature thermometer, like this one and track on graph paper.
Each day, before getting out of bed and at about the same time, take your temperature and track it. What you should notice is irregular and lower temps during the first half of the month, a one degree jump in the middle of the month and steadier, higher temperatures from that point on until a drop and the start of the menstrual cycle.
In PCOS, we often see very irregular temps all month, or for longer, and this is consistent with not ovulating.
In the youtube series, I go into more depth on this and show some examples of charts from my own fertility journey to give you a better idea.
I hope you found this helpful! If you’d like more information on addressing your PCOS from the root, check out my course- Functional PCOS or my Functional PCOS group program!