When you are diagnosed with PCOS, I'm pretty sure its standard procedure to immediately be recommended the birth control pill, often alongside Metformin and/or an anti-androgen like Spironolactone.
Polycystic Ovarian Syndrome (PCOS) is the leading cause of infertility in women and is believed to affect up to 1 in 5 women!
I agree that the drugs used are effective at 'managing' symptoms, but sadly they can come alongside a whole host of negative effects and when you stop taking them, the symptoms often return with a vengeance!.
I'm not 'anti-pharmaceuticals'. I always say that if I ever get hit by a car, I wan't to be taken straight to A&E and given all the pain relieving drugs they have. This is not the time to see an acupuncturist or nutritionist.
Medications certainly have their time and place, however I don't believe they should be a first resort. Especially if someone isn't addressing some of the basics of hormonal health like regulating blood sugar, exercising, sleeping well, managing stress etc.
I am frequently asked to share the potential pro's and con's of the common PCOS medications. In this blog post I will be doing just that, however please remember that this is NOT MEDICAL ADVICE and everyone has a different experience with different treatment options.
This relatively inexpensive drug is commonly used as treatment for type 2 diabetes, but is also recommended for many women with PCOS due to its actions on insulin. Insulin resistance is the biggest driver of PCOS (believed to affect around 80% of women with this condition) as excessive insulin levels stimulate the ovaries to produce high amounts of androgens like testosterone.
Metformin works by improving the sensitivity of peripheral tissues to insulin which results in a reduction of circulating insulin levels. Metformin inhibits gluconeogenesis (production of new glucose) in the liver, increases the glucose uptake by peripheral tissues and is believed to alter the way that carbohydrates are absorbed in the intestine.
Many women experience gastrointestinal side effects including nausea, bloating, cramping and loose stools as metformin causes a four fold increase in abdominal symptoms. This is because Metformin is an antibiotic, and can significantly alter gut flora. It is well known that women with PCOS often have some degree of intestinal dysbiosis whether that is due to a gut infection like SIBO, or low diversity of bacterial species.
It is common for women with PCOS to have elevated levels of lipopolysaccharide (LPS), which is the major component of the outer membrane of Gram-negative bacteria. High levels of this compound can lead to intestinal permeability (aka 'leaky gut'), chronic inflammation and even insulin resistance. After treatment with Metformin, gut bacteria seem to produce more anti-inflammatory compounds such as butyrate and short chain fatty acids (SCFA's), which are all associated with metabolic improvements.
Several short term studies on metformin have associated it with a reduction in miscarriage rate and gestational diabetes in insulin-resistant women with PCOS, with no increase in major birth defects. Unfortunately, there are no real long term studies following the outcomes in babies whose mothers took metformin in pregnancy, so as of now its safety during pregnancy is unknown.
That being said, a 2018 study showed that children of mothers who took Metformin during pregnancy had almost double the rate of childhood obesity as compared to children of mothers who didn't. By age four, 32% of the metformin children were overweight or obese.
As you improve your diet and lifestyle, it is important that you closely monitor your blood sugar levels to prevent hypoglycaemic events. If you have hypothyroidism or Hashimoto's, be aware that your thyroid medication may reduce Metformin's potency and metformin may affect your thyroid function.
Metformin also depletes vitamin b12, folate and potentially the antioxidant co-enzyme Q10, therefore all women on this medication should be supplementing with these vitamins in their 'active' forms.
Spironolactone is a synthetic steroidal 'anti-androgen' drug that is very similar to the synthetic progestin 'Drospirenone' used in the birth control pills Yasmin and Yaz. Spironolactone fits into (& blocks) your testosterone receptor and reduces production of this hormone, which is why it’s used, however it has no effect on the 5-alpha reductase enzyme and can also disrupt ovulation, oestrogen metabolism and adrenal function. Because of its effects on lowering androgen levels, many women find that it does effectively reduce androgenic hair loss and clear hormonal acne. However it does come with some risks.
It can cause loss of libido, menstrual irregularity, breast pain and has actually been linked with breast cysts, and possibly breast cancer. By interfering with your hypothalamic-pituitary-adrenal (HPA) axis (which is commonly dysfunctional anyway in women with PCOS), spironolactone can lead to low blood pressure, headaches, fatigue, depression and increases the risk of blood clots.
It is ordinarily prescribed as a diuretic to lower blood pressure while simultaneously preserving potassium levels, which can be beneficial for people with kidney disease. Because of this interference with aldosterone and potassium levels in the body, Spironolactone can have many serious side effects and it is important that potassium levels are regularly checked and need to avoid dehydration as this could be fatal. Signs of potential dehydration to watch out for include constipation, dry mouth, dry skin, headaches, low blood pressure, dizziness and anxiety.
Some research suggests that spironolactone has the potential to feminize male foetuses during early pregnancy, and cause hormonal problems in late pregnancy, by inhibiting the activity of male hormones. For this reason Spironolactone is strictly contraindicated when trying to conceive, hence why the birth control pill and Spironolactone are commonly paired together.
Birth Control Pills
Most women with PCOS are prescribed the Pill to 'manage' their symptoms, however it can put women at risk of developing (or exacerbating) imbalances that these women are already at high risk of. Crazy right?
They can aggravate insulin resistance, increase inflammation levels, deplete crucial nutrients and increase the risk for conditions like cardiovascular disease and type 2 diabetes.
Certain birth control pills like Yasmin can elevate blood glucose levels and it was found that the occurrence of Type 2 diabetes in women currently taking the pill was 60% higher than those who had never been on the Pill.
It is also an endocrine disrupter, meaning that it interferes with our own natural hormone production. The pill is so effective against pregnancy because it completely shuts down the communication between the brain and our ovaries. The feedback communication loops are often disrupted in women with PCOS anyway, therefore this could make the situation worse.
The synthetic hormones in the pill increase sex hormone binding globulin (SHBG) levels, which acts like a sponge to 'soak up' excess hormones like testosterone in the bloodstream. Unfortunately, the pill is believed to genetically alter the liver which can lead to long term elevations in SHBG, even after stopping the pill.
Post birth control syndrome (PBCS) is another condition that can develop after stopping the pill. Around the 3 month mark, hormonal symptoms like acne, hair loss and PMS can worsen as your own natural hormones try to regulate. Androgenic symptoms can be particularly bad during this time, as your body can go through an 'androgen rebound' effect.
Polycystic ovary syndrome represents 80% of anovulatory infertility cases and clomid treatment is often the first medication choice to stimulate ovulation. Clomid is one of the most commonly used pharmaceuticals in the treatment of fertility concerns today.
It works by binding to oestrogen receptors and inhibiting the action of oestrogen (which is produced by developing follicles) on the hypothalamus in the brain. As a result, the pituitary gland perceives oestrogen levels to be low (when they actually are not), and it responds by producing increased levels of both LH and FSH.
This causes increased follicle production by the ovaries, and stimulation of ovulation. As effective as this therapy can be at inducing ovulation, studies have indicated fertility specific side effects of clomiphene, many of which are caused by its opposition to oestrogen.
Clomid thins the endometrial lining and reduces the amount of fertile mucus. It also has a half-life of a week, meaning that the drug and it’s effects linger in the body for quite some time. This results in additive negative side effects, especially for patients doing more than one Clomid cycle in a row. And finally, Clomid raises the incidence of multiple births tenfold, increasing the rate of complications during pregnancy and delivery
It is actually believed that as many as 40% of women with PCOS are 'clomid-resistant', meaning that it simply doesn't work. Also women with PCOS have a higher than normal risk for developing ovarian hyper-stimulation, a potentially dangerous complication of fertility treatments.
As you now know, there are a lot of potential side effects that your Doctor may not bring to your attention.
Here are some of the natural alternatives to these common PCOS medications...
> Nutrition & Lifestyle Changes
If you haven't already, changing your nutrition and lifestyle is the first step you need to take if you want to reverse your PCOS symptoms. You just can't out-supplement a bad diet, a sedentary lifestyle or stressed out adrenals.
You need to start with these changes regardless of what type of PCOS you have or combination of symptoms.
If you haven't already, have a look through some of my detailed blog posts on the subject of PCOS. But as an overview, it is important to first...
Maintain a healthy body weight
Eat a blood sugar balancing diet
Sleep 7-9 hours each night
Avoid endocrine disrupting chemicals
Move your body daily (but avoid over exercising)
Manage your stress levels
This herb is believed to be an insulin sensitising agent and it has been successfully used for many decades in Traditional Chinese Medicine (TCM) for the treatment of type 2 diabetes.
It has similar mechanisms to metformin with the same levels of efficacy (if not better) and also creates alterations to the gut microbiome, without nearly as many side effects. It is believed to be less systemically absorbed than Meformin, meaning that its actions are mainly focused on the microbiome, rather than the mitochondria and other cellular functions.
Berberine has an excellent anti-inflammatory profile and is also used to aid healthy weight loss, (particularly visceral fat) and to normalise triglyceride and cholesterol levels.
Berberine isn't recommended long term because of it's antimicrobial actions on the gut microbiome. It is also contraindicated with many pharmaceutical drugs and health conditions so check with your health practitioner before using.
One of the most researched supplements for PCOS. There are two major forms of inositol - myo-inositol and d-chiro-inositol. Inositol (aka vitamin B8) is an intracellular messenger involved in insulin signalling. Women with PCOS tend to have lower levels of inositol due to increased urinary excretion.
A 2018 meta-analysis of ten randomised trials found that inositol significantly improves markers of insulin resistance and “appears to regulate menstrual cycles, improve ovulation and induce metabolic changes in polycystic ovary syndrome”.
Inositol is generally safe for most people to use as it doesn't interact with many medications, however it may cause slight gastrointestinal symptoms such as loose stools and bloating for some individuals. I recommend starting at a low dose and slowly increasing, to prevent this.
Some researchers suspect that a magnesium deficiency may contribute to the development of insulin resistance and type 2 diabetes. Magnesium deficiency affects at least one-third of individuals, and probably more, and cannot be easily or reliably diagnosed by a blood test. It is often referred to as 'natural metformin' because of its beneficial effects on blood glucose regulation and metabolic markers.
Because of stress, soil depletion and farming methods, it is hard for us to get the amount of magnesium we require from diet alone. Although magnesium supplementation is contraindicated with certain medications (check with your practitioner), a good way to support your daily requirements is to use epsom salt baths and/or topical magnesium oil spray.
> N-acetylcysteine (NAC)
N-acetylcysteine is a powerful anti-oxidant that can be useful in the treatment of PCOS. A 2017 study found NAC out-performed Metformin in managing cholesterol, fasting blood glucose and fasting insulin in women with PCOS.
For women taking clomid or undergoing assisted reproductive techniques, NAC can improve egg quality, ovulation, pregnancy, live birth rates and potentially reduce the risk of preterm labour.
Several studies have compared NAC and metformin in women with PCOS. Women who took NAC showed similar results to metformin for improving insulin resistance as well as lowering cholesterol levels, and without the common gastrointestinal side effects that metformin can cause.
Individuals with a sulphur sensitivity or CBS genetic mutation may need to supplement with smaller doses of NAC or add in the trace mineral molybdenum to prevent symptoms like bloating, diarrhoea and brain fog.
> Black Cohosh
This herb is believed to improve FSH/LH ratios and improve ovulation rates in women with PCOS. It also helps to inhibits the 5-alpha reductase enzyme (which is responsible for the production of the potent androgen DHT) which may benefit skin that exhibits symptoms of elevated androgen levels.
In one study conducted in 2008, black cohosh was found to significantly increase oestradiol and LH concentrations in patients taking clomid. Endometrial thickness, serum progesterone and clinical pregnancy rates in patients were significantly higher in the black cohosh group as compared to control.
It is thought to function as a phyto- oestrogen, however other studies have shown it to have many different mechanisms of action, ranging from serotonin-like effects to anti-inflammatory effects.
It should be noted that Black Cohosh should be viewed as a prescription medication to be used only under the supervision of a physician. It should never be used by patients with compromised liver function and has numerous drug interactions.
I highly recommend working with a skilled practitioner who can help you figure out what works best for you. If you would like further 1-on-1 support, check out my 4 month
PCOS SOS package.
This is designed to help you identify and address the root causes of your PCOS.
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Do you have any experience with one of these medications or natural alternatives?
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Conventional fertility approach: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4642490/
Metformin : https://www.ncbi.nlm.nih.gov/pubmed/22117616
Metformin childhood obesity:https://www.ncbi.nlm.nih.gov/pubmed/29490031
Magnesium/insulin resistance: https://www.sciencedirect.com/science/article/abs/pii/S0899900717300229?via%3Dihub
NAC for PCOS: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4306416/
NAC vs Metformin: https://www.ncbi.nlm.nih.gov/pubmed/26654154
NAC systemic review : https://www.hindawi.com/journals/ogi/2015/817849/
Herbal medicine for PCOS: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4528347/
PCOS SOS - Dr Felice Gersh
8 Steps to Reverse your PCOS - Fiona McCulloch
Period Repair Manual - Dr Lara Briden
The Hormone Cure - Dr Sara Gottfried