PCOS: A multifactorial condition that requires a multifaceted approach

Written by: Jordan Robertson ND  

Polycystic ovarian syndrome is the most common hormonal condition in women and affects both metabolic hormones such as insulin and sex hormones such as estrogen, progesterone and testosterone¹. The hallmark feature of PCOS is elevated insulin levels, which interferes with ovulation, elevates free testosterone and contributes to central weekend and increased cardiovascular risk factors². Women with PCOS may experience irregular or absent menstrual cycles, signs of elevated testosterone such as unwanted hair growth or acne or struggle with weight management².  

The diagnosis of PCOS includes a history of irregular menstruation, signs of high testosterone and bloodwork that confirms high testosterone. Women with PCOS benefit from a thorough assessment once diagnosed, to assess her ovulation, insulin resistance³ and signs of inflammation through testing markers such a CRP⁴, ferritin⁵ and white blood cells⁶. Women with PCOS have lower levels of vitamin D than other women and when women with PCOS are treated for their vitamin D deficiency⁷, they see improvement in symptoms⁸.  

Nutrition and lifestyle recommendations are important pillars in the health plan of women with PCOS at all stages of life. Women with PCOS are at a higher risk for miscarriage and pregnancy complications⁹ as well as cardiovascular disease and diabetes as they age³. Supporting women with nutrition and lifestyle recommendations that encourage minimal processed foods¹⁰ and a Mediterranean style diet¹¹ as well as encouraging daily movement¹² and exercise decrease insulin resistance and encourage ovulation and better hormone regulation.  

Women with PCOS may benefit from the addition of nutrients to their health plan such as inositol, fish oil and vitamin D.  

Inositol is a b-vitamin like nutrient that can be made in the body or ingested through food and supplement sources. Inositol acts as an insulin second-messenger, reducing fasting insulin levels, improving blood sugar and restoring ovulation in women with PCOS¹³. Inositol has been researched widely in the PCOS population and supports regulating menstruation¹⁴, egg quality¹⁵ and reduces the risk of gestational diabetes in women when they fall pregnant¹⁶.  

Fish oil has supports cardiovascular risk factors and has anti-inflammatory actions in women with PCOS¹⁷. Studies have shown that adding fish oil to the diet and lifestyle of women with PCOS helps reduce their markers of insulin resistance and elevated androgens^8,18. Perhaps most importantly, fish oil has been shown to reduce the symptoms of low mood^8,18 in women with PCOS, which is a common concern in women with PCOS.  

Vitamin D is commonly deficient in women with PCOS and should be tested as part of a comprehensive work up in these patients^19,20. Vitamin D deficiency worsens insulin resistance and may contribute to the worsening of other symptoms of PCOS such as irregular cycles, acne and low mood^7,8. When women with PCOS are treated with vitamin D in combination with dietary and lifestyle advice they have improvements in blood markers associated with PCOS²¹.  

Given the multifactorial impact PCOS has on the body, it requires an equally multifaceted approach. Combining thorough assessment, dietary and lifestyle advice and the addition of key nutrients such as inositol, fish oil and vitamin D, women with PCOS can improve their symptoms and their overall experience of their condition.  

1. Deswal, R., Narwal, V., Dang, A. & Pundir, C. S. The Prevalence of Polycystic Ovary Syndrome: A Brief Systematic Review. J. Hum. Reprod. Sci. 13, 261–271 (2020). 

2. de Melo, A. S. et al. Pathogenesis of polycystic ovary syndrome: multifactorial assessment from the foetal stage to menopause. Reprod. Camb. Engl. 150, R11-24 (2015). 

3. Goodman, N. F. et al. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS, AMERICAN COLLEGE OF ENDOCRINOLOGY, AND ANDROGEN EXCESS AND PCOS SOCIETY DISEASE STATE CLINICAL REVIEW: GUIDE TO THE BEST PRACTICES IN THE EVALUATION AND TREATMENT OF POLYCYSTIC OVARY SYNDROME–PART 1. Endocr. Pract. Off. J. Am. Coll. Endocrinol. Am. Assoc. Clin. Endocrinol. 21, 1291–1300 (2015). 

4. Escobar-Morreale, H. F., Luque-Ramírez, M. & González, F. CIRCULATING INFLAMMATORY MARKERS IN POLYCYSTIC OVARY SYNDROME: A SYSTEMATIC REVIEW AND META-ANALYSIS. Fertil. Steril. 95, 1048-58.e1–2 (2011). 

5. Yin, J., Hong, X., Ma, J., Bu, Y. & Liu, R. Serum Trace Elements in Patients With Polycystic Ovary Syndrome: A Systematic Review and Meta-Analysis. Front. Endocrinol. 11, (2020). 

6. Palomba, S. et al. Low-Grade Chronic Inflammation in Pregnant Women With Polycystic Ovary Syndrome: A Prospective Controlled Clinical Study. J. Clin. Endocrinol. Metab. 99, 2942–2951 (2014). 

7. Mogili, K. D. et al. Prevalence of vitamin D deficiency in infertile women with polycystic ovarian syndrome and its association with metabolic syndrome – A prospective observational study. Eur. J. Obstet. Gynecol. Reprod. Biol. 229, 15–19 (2018). 

8. Jamilian, M. et al. The influences of vitamin D and omega-3 co-supplementation on clinical, metabolic and genetic parameters in women with polycystic ovary syndrome. J. Affect. Disord. 238, 32–38 (2018). 

9. Boomsma, C. M. et al. A meta-analysis of pregnancy outcomes in women with polycystic ovary syndrome. Hum. Reprod. Update 12, 673–683 (2006). 

10. Gill, V., Kumar, V., Singh, K., Kumar, A. & Kim, J.-J. Advanced Glycation End Products (AGEs) May Be a Striking Link Between Modern Diet and Health. Biomolecules 9, (2019). 

11. Mirabelli, M. et al. Mediterranean Diet Nutrients to Turn the Tide against Insulin Resistance and Related Diseases. Nutrients 12, (2020). 

12. Dos Santos, I. K. et al. The effect of exercise as an intervention for women with polycystic ovary syndrome: A systematic review and meta-analysis. Medicine (Baltimore) 99, e19644 (2020). 

13. Merviel, P. et al. Impact of myo-inositol treatment in women with polycystic ovary syndrome in assisted reproductive technologies. Reprod. Health 18, (2021). 

14. Gerli, S., Papaleo, E., Ferrari, A. & Di Renzo, G. C. Randomized, double blind placebo-controlled trial: effects of myo-inositol on ovarian function and metabolic factors in women with PCOS. Eur. Rev. Med. Pharmacol. Sci. 11, 347–354 (2007). 

15. Facchinetti, F. et al. Breakthroughs in the Use of Inositols for Assisted Reproductive Treatment (ART). Trends Endocrinol. Metab. TEM 31, 570–579 (2020). 

16. Zhang, H., Lv, Y., Li, Z., Sun, L. & Guo, W. The efficacy of myo-inositol supplementation to prevent gestational diabetes onset: a meta-analysis of randomized controlled trials. J. Matern.-Fetal Neonatal Med. Off. J. Eur. Assoc. Perinat. Med. Fed. Asia Ocean. Perinat. Soc. Int. Soc. Perinat. Obstet. 32, 2249–2255 (2019). 

17. Salek, M., Clark, C. C. T., Taghizadeh, M. & Jafarnejad, S. N-3 fatty acids as preventive and therapeutic agents in attenuating PCOS complications. EXCLI J. 18, 558–575 (2019). 

18. Amini, M. et al. The effects of fish oil omega-3 fatty acid supplementation on mental health parameters and metabolic status of patients with polycystic ovary syndrome: a randomized, double-blind, placebo-controlled trial. J. Psychosom. Obstet. Gynaecol. 1–9 (2018) doi:10.1080/0167482X.2018.1508282. 

19. Wehr, E. et al. Association of hypovitaminosis D with metabolic disturbances in polycystic ovary syndrome. Eur. J. Endocrinol. 161, 575–582 (2009). 

20. Bacopoulou, F., Kolias, E., Efthymiou, V., Antonopoulos, C. N. & Charmandari, E. Vitamin D predictors in polycystic ovary syndrome: a meta-analysis. Eur. J. Clin. Invest. 47, 746–755 (2017). 

21. Foroozanfard, F. et al. Effect of Two Different Doses of Vitamin D Supplementation on Metabolic Profiles of Insulin-Resistant Patients with Polycystic Ovary Syndrome: A Randomized, Double-Blind, Placebo-Controlled Trial. Horm. Metab. Res. Horm. Stoffwechselforschung Horm. Metab. 49, 612–617 (2017).