Category B CE Credits - Labs and treatment options for PCOS with Dr. Jodie Peacock, ND

Dr. Jodie Peacock is a practicing naturopathic doctor in Oakville, Ontario. Her practice focuses on hormone health and fertility. She is the author of ‘Preconceived’, the Founder of the ‘Canadian Fertility Show’, and on the Board of Directors at the Ontario Association Of Naturopathic Doctors (OAND). She is passionate about hormone health, given her first-hand experience with PCOS. She has also worked with Nutritional Fundamentals for Health (NFH) since 2008.

Q. How does one diagnose PCOS?

A. 5-10% of women of reproductive age are diagnosed with PCOS. Common symptoms include irregular menses, hirsutism (hair growth), acne, and weight gain.. Clinicians follow the Rotterdam criteria for diagnosis, which requires 2 out of 3 of the following to be present: irregular or absent ovulation, high levels of androgens, and/or enlarged ovaries containing at least 12 follicles each ovary.

Q. When do most women come into your clinic?

A. Usually, teenagers see a family doctor when their menstrual cycles are irregular or late and they develop cystic acne. They will often be prescribed oral contraceptive pills (OCPs) to regulate the cycle, which often helps with acne. Women usually come to naturopathic doctors when they are trying to conceive as the OCP has not addressed the underlying issues.

Q. What is usually going wrong hormonally?

A. Androstenedione: Excess androstenedione gets converted to estradiol which stimulates the pituitary to secrete LH. FSH drops and androgens increase by negative feedback regulation from LH increase. High androgen leads to the maturation of small follicles by reducing 17b-estradiol (E2) secretion, which is very important. The sonography will show multiple follicles forming but not sizable enough to ovulate or of good enough quality to be an embryo.

Testosterone: Total testosterone, sex hormone binding globulin (SHBG) and free testosterone are all important to check because one may look normal while the other is imbalanced. For example, a normal testosterone and low SHBG can have high free testosterone which may result in signs/symptoms of androgen excess, such as hirsutism and acne.

Fasting Glucose and Insulin: 30-40% of the PCOS population have insulin resistance which leaves them more prone to type 2 diabetes. Patients may have elevated fasting glucose but more often we see elevated fasting insulin and that is why it is important to run both.

Prolactin and Androstenedione: Androstenedione is the precursor to aldosterone, testosterone, and estrogen. In PCOS, they all show elevated levels. Prolactin, secreted by the anterior pituitary gland and should only see an increase if someone is lactating or in pregnancy. Outside of that, it should be low, but it can be affected by PCOS.

Thyroid: Research has shown that people with PCOS have a much higher propensity to have Hashimoto’s thyroiditis. The thyroid, from a fertility standpoint, requires a TSH under 2.5mIU/L. T3/T4 should be somewhere in the middle range. Clinicians will often test TSH  and  T4  but not look for antibodies. They should be looking for anti-TPO and anti-TG, which should not be present, because they can impact conception.

LH/FSH, Estrogen and Progesterone: Follicular stimulating hormone (FSH) signals the growth of follicles. And luteinising hormone (LH) triggers ovulation. If the ratio of LH to FSH is > 3:1, it aids in diagnosing PCOS. Elevated FSH levels can show primary ovarian insufficiency or signs of menopause.

Estrogen levels can sometimes increase with PCOS. Progesterone is generally tested seven days before a period; however, with irregular cycles, this can be difficult. Progesterone must be in a good range to maintain a healthy pregnancy, at least for the first ten weeks.

CRP: PCOS patients often have low-grade inflammation, which is prone to cardiovascular risks. If CRP is elevated, this should be addressed before going into a pregnancy.

AMH: Elevated AMH inhibits follicle development and can be a problem while trying to get pregnant. Preclinical studies suggest elevated AMH levels may be a contributing factor to the central pathophysiology of PCOS and other reproductive diseases. At that elevated level, it leaves the person at higher risk for ovarian hyperstimulation syndrome (OHSS). It causes a lot of pain and pressure in the ovaries and can make IVF transfers difficult.

Q. As a naturopathic doctor, how do you support women with PCOS?

A. We look at parameters like ovulation, weight, development of follicles, levels of androgens, blood sugar and cortisol regulation which can be addressed with the following:

Diet: Focus on vegetables, fruits and lean proteins. Being vegan or vegetarian can be a big challenge with PCOS as you want to get at least 80g or more of protein per day, which can be challenging to get from vegetarian sources. Often you may need to involve protein powders. Ensure adequate healthy fats from sources such as fish, seeds, nuts, avocados, and olive oil. Minimize grains and refined sugars. Often, they are better on a low or no-grain diet. It doesn’t mean you’re eliminating carbs because you replace them with beans and legumes, where you also get fibre, but rather eliminating processed carbs and faster absorbing ones.

Intermittent fasting: Something very commonly recommended for insulin resistant patients is intermittent fasting. The 16/8 break-up is easier to follow, which is 16 hours of fasting and 8 hours of eating. You can do three meals or two big meals and a snack. It has proven effective in reducing Insulin Growth Factor-1 (IGF-1) and Insulin-like Growth Factor-Binding Protein 1 (IGFBP1). We also see an increase in leptin levels. These have beneficial effects on ovarian function, androgen excess and infertility in PCOS women.

Leptin and Ghrelin: The hormones leptin and ghrelin are essential in understanding hunger and satiety. Ghrelin is secreted when you are hungry, while leptin is secreted to signal you are full. Often patients with PCOS have reduced sensitivity to leptin, so even though leptin is secreted, it’s not necessarily getting bound to the receptors, so they aren’t necessarily getting the signal of being full and are prone to overeating.

Leptin has a soluble leptin receptor (sOB-R) that circulates in the blood and can bind to leptin. In PCOS, leptin level (ng/ml) and free leptin index (FLI) increased significantly, while sOB-R (ng/ml) significantly decreased compared to control subjects.

Exercise: Research has shown that exercise helps reduce androgen levels, improves egg quality, and regulates ovulation. Moderate exercise, five or more hours a week, shows a positive impact. Consider HIIT 2-3 times per week to support leptin sensitivity.

Q. What is a moderate exercise routine?

A. Moderate exercise is 30-60 minutes 5-7 days per week. Aim at 50-70% of max heart rate. For women in their 30s, aim for a heart rate of 140-160bpm. Some women might be able to hit this with a brisk walk, while others may require increased intensity. If exercise isn’t a big part of your practice, having a personal trainer is a great idea.

Q. What are some recommended supplements?

A. Myo-Inositol: Myo-Inositol plays a vital role in the ovaries. It helps glucose uptake in cells, which supports energy. It improves FSH signaling, allowing for better germ cell (oocyte) maturation. In PCOS, we see significant changes in hormonal balance, so it restores regular ovulation & ovarian function (LH, FSH, E2), decreases serum testosterone and improves insulin sensitivity. It also reduces the risk of OHSS.

In a trial where IVF patients with PCOS were given a 4g/day myo-inositol dosage, improved oocyte quality was observed. Pregnancy rates were also significantly better. We also see further benefits when combining myo-inositol with melatonin-supplemented groups, like reduced hyperinsulinemia, improved insulin sensitivity, and improved balance in LH, prolactin, and testosterone levels.

N-Acetyl cysteine (NAC): NAC has several amazing functions that work as a precursor for your liver to make glutathione. Women with PCOS and undergoing ICSI procedures took 600 mg of NAC three times per day or 1500mg/day of metformin for six weeks leading up to egg retrieval. The NAC group had fewer immature or abnormal oocytes and a higher number of good-quality embryos. This study proved NAC is a viable alternative to metformin in this situation.

Melatonin: Melatonin has a role in steroidogenesis, folliculogenesis, and oocyte maturation. Both melatonin and its receptors can be detected in primordial follicles. Levels of melatonin in follicular fluid (FF) are high pre-ovulation, especially in large antral follicles, which typically end up ovulating. High concentrations of melatonin can suppress follicular atresia.

In 40 normal-weight women with PCOS, we observed melatonin treatment significantly decreased androgens levels, FSH levels and AMH serum levels.

Almost 95% of participants experienced an improvement in their menstrual cycles. Concentrations of IL-6, TNF-a, and IL-18 are higher in PCOS patients. After melatonin administration, these are reduced and regulated.

CoQ10: In a trial over 12 weeks, 40 women diagnosed with PCOS were given 100mg CoQ10 per day. Improved gene expression related to insulin, lipid metabolism and inflammation was seen. In people with a poor ovarian response (<35), a higher dosage of 200mg three times a day for 60 days before IVF was given. It was observed that more embryos survived to day 3 (8% in the treatment group had no day three embryos, and 22% in the placebo group)

Acetyl-L-Carnitine: Acetyl-L-Carnitine is a known antioxidant that has shown protective effects on growing embryos. Carnitine transports long-chain fatty acids across the inner mitochondrial membrane.

If someone is deficient in carnitine, it is harder for them to get fatty acids into the mitochondria. We need enough energy for DNA replication, and carnitine reverses the age-associated decline of mitochondrial membrane potential. A study in vitro shows that carnitine added to embryo cultures challenged by oxidative stress reduced DNA damage, improved chromosomal structure and developed blastocysts. Non-obese women with PCOS have low levels of L-carnitine and sex hormone-binding globulin (SHBG) compared to healthy women. Low levels of L-carnitine are linked to hyperandrogenism and insulin resistance in PCOS patients. In a study with 85 clomiphene-resistant, PCOS patients were given 3g of L-carnitine in addition to 250mg clomiphene citrate showing improved ovulation, pregnancy rates, body mass index and even lipid profiles.

R-alpha lipoic acid (R-ALA): R-alpha lipoic acid is looked at when patients have insulin concerns. 400mg ALA over 12 weeks given to patients with PCOS and obesity, improved metabolic parameters such as body mass index and insulin were seen. After three months, ALA + Myo-inositol in 36 obese PCOS patients improved metabolic parameters and oocyte quality.

Folate and B12: Women with PCOS, homocysteine concentrations are higher and B12 is often lower. Insulin resistance, obesity, and elevated homocysteine were associated with lower serum vitamin B12 concentrations in PCOS patients.

L-methyl-folate increases peripheral insulin sensitivity. Healthy folate levels can restore normal homocysteine levels. Elevated homocysteine levels are risk factors for cardiac concern and must be examined.

Omega-3 Fatty Acids: In a 6-month trial, non-obese women diagnosed with PCOS given 1500mg/day of omega fatty acids had improvements in hirsutism, fasting insulin levels, lower testosterone, LH and increased sex-hormone binding globulin. One could achieve this by consuming omega-3 supplements or a diet of cold-water fish three times per week.

Vitamin D: Vitamin D deficiency has been linked to infertility. Up to 85% of women with PCOS are vitamin D deficient. Multiple studies show women with sufficient levels are more likely to achieve spontaneous pregnancy and have better-quality embryos if undergoing IVF procedures.

Q. How often do you see women with PCOS develop gestational diabetes once they conceive?

A. There is a higher risk of gestational diabetes for women with PCOS. The best solution is to continue with the measures one began when trying to conceive. If you don’t take those measures, the risk of developing gestational diabetes is high, which also puts your offspring at risk of developing type 2 diabetes.

About Dr. Jodie

Dr. Jodie Peacock B.Sc., N.D.is a Naturopathic doctor at The Root of Health in Oakville.

Jodie is a University of Guelph graduate and completed 4 years of study at the Canadian College of Naturopathic medicine. She has a special interest in women’s health concerns including hormone balancing addressing the adrenals, thyroid and ovarian function. This can help symptoms associated with fertility, PCOS, menopause, weight gain and fatigue.

Jodie is passionate about educating couples on how to optimize their fertility and the health of their future children. She authored Preconceived to support as many couples as possible through the wealth of research on the impact of diet and lifestyle changes with regards to conception. Preconception health is critical to ensuring the optimal health of our future generation.

Dr. Jodie Peacock’s passion for naturopathic medicine stems from the ability to spend quality time with her patients helping to treat the whole person instead of just their symptoms. She feels very strongly about the opportunity to educate patients and the general public in the use of effective alternative treatments, empowering them to take control of their own health. This is one of the reasons she started the Canadian Fertility Show to educate the general public.