PCOS treatment options

What you can do to treat your PCOS

Please refer to my previous post for a description of PCOS pathologies.  What follows is a brief layout of different treatments.   Going through them all, and experimenting and finding what works best, and talking to your doctor and doing your own research is all critical.   This is just what I have found, both on the web and in my body.   Note that the section on diet does not stand alone.  There is more information on the role different foods play in PCOS is in the post to which I just linked.  Below is the Rock to get us started.  Woop!



If you are an overweight PCOS patient, I recommend that you eat low carbohydrate (specifically fructose) to decrease insulin and testosterone levels.  Try and stick to glucose and safe starches when you do eat carbohydrates.  These include potatoes, sweet potatoes, yams, and white rice.  Fixing the metabolic syndrome that may be the causative root of your PCOS is a bit more complicated than this, but people seem to have success with this method across the board.  Low carbohydrate diets tend to mitigate insulin signalling problems, which in turn helps with PCOS.

If you are an overweight PCOS patient, also, try fasting.  Fasting, especially for people with overburdened metabolisms who are trying to lose weight, increases insulin sensitivity and helps the weight slide off.

If you are a thin PCOS patient, eat high carbohydrate.  Carbohydrates elicit a greater leptin response than fat.  Leptin is responsible for telling your hypothalamus that you are well fed.  If you are someone who often feels hungry or who recently lost weight, you may want to seriously consider this idea.  If your body thinks it is starving, it will not perform reproductive functions.

Similarly, if you are a thin PCOS patient, do not fast.  Fasting decreases leptin levels.

If you are a hypothyroid PCOS patient, eat a high carbohydrate diet, at least 50 percent of calories, a la Ray PeatChris Kresser and PHD.  This is because glucose is necessary for the conversion of T4 into T3 in the liver.  Without glucose, less T3 is synthesized, such that many cellular functions, such as reproduction, slow down.

Don’t eat fructose.  For overweight PCOS patients, fructose can inhibit leptin signalling and make you hungrier.  Fructose is significantly, insidiously implicated in weight gain.  For thin PCOS patients, fructose directly inhibits the reception of leptin in the hypothalamus.  This is another factor that makes it difficult for the body to perceive whether or not it is being fed.

Don’t eat soy.  Soy is the most potent phytoestrogen.  Not only does soy beget PCOS by hindering the production of true estrogen, but it is also implicated in reproductive cancers.

Don’t eat legumes, which also contain phytoestrogens.  This means all forms of beans and peas.

Don’t eat dairy.  It’s androgenic.   Having too many androgens in the bloodstream is one of the primary drivers of PCOS.

Lower the amount of cruciferous vegetables you eat (if you eat them a lot).  Brassica plants activate an enzyme (cytochrome P450) in the liver which clears estrogen out of the body.  Additionally, if cruciferous vegetables are consumed often in the raw form, they act as goitrogens and can decrease thyroid function.

Eat plenty of fat.  Fat is crucial for the production of hormones.   And cholesterol.  Cholesterol is one of the root molecules in endocrine production.  Good fats to focus on are the monosaturated fats–olive oil, avocado, and macadamia oil–and saturated fat in the form of coconut oil or organic animal products.

Steer clear of Omega 6 PUFAs.  Omega 6 fats are associated with increased testosterone levels in both women and men, in addition to causing excessive inflammation.  This means limiting soy, canola, rapeseed, vegetable, and corn oils.  Nuts in their natural form should also be avoided because they are primarily omega 6 fats, and also because they contain phytoestrogens.

Eat grapefruit.  Grapefruit inhibits the cytochrome P450 I mentioned above that clears estrogen out of the body.  This is a nice trick to increase estrogen levels, but note also that it is not a permanent fix, and that the activity of cytochrome P450 is still crucial for your health.

Eat magnesium rich foods to increase insulin sensitivity.

Eat beta carotene containing foods to increase progesterone levels.  The corpus luteum has the highest concentration of beta-carotene of any organ in the body, suggesting that this nutrient plays an important role in reproductive processes.

Eat foods good for the liver.  The best are high in choline, such as eggs and organs.

Eat organic meat or wild game, not factory farmed meat, as often as possible.  The hormone levels are guaranteed to be natural and to disrupt your system as little as possible.

Drink spearmint tea.  It’s fairly highly regarded as a testosterone blocker.



Honestly, in my personal experience, I have rarely witnessed benefits from supplements.   In fact, the biggest changes I experience are usually negative and from overdoses, probably because I eat a rich enough diet already.  So if you eat a range of vegetable and animal products, supplementation should not be too much of an issue.    If you want to supplement for general health, I recommend checking out the Jaminet’s list of supplementation in their book, or which can be figured out over at their blog.   Please use the organic (that is, carbon-based), chelated forms of any mineral supplements you take.  Magnesium oxide, for example, is something you do not want to take because it’s basically eating crunched up metals.  Instead, take a form of magnesium that is “bio-available,” or “chelated,” which means that it is a part of a molecule your body can actually use.

Supplementation to correct specific deficiencies, however, can be very helpful.  If you’re worried specifically about your ovaries and your fertility, here is a list of supplements I have witnessed being efficacious:

On his podcast, Robb Wolf  recommends that women with PCOS or androgen-dominant type symptoms try to boost their thyroid functioning with iodine supplementation.  His clients are apparently satisfied and ‘healed’ by taking iodine.  If you really suspect your thyroid in your pathology, however, I recommend getting your blood tested for levels of TSH, T3, and T4 at least before proceeding.   Iodine can help with hypothyroid, especially if its an iodine deficiency causing the problem, but iodine can also hinder thyroid functioning in clinical hypothyroid cases, especially if the underlying problem is the autoimmune disease Hashimoto’s thyroiditis rather than a simple iodine deficiency.

Chromium helps to encourage the formation of glucose tolerance factor which is a substance released by the liver and which is required to make insulin more efficient. A deficiency of chromium can lead to insulin resistance.  Because of this, it is the most widely researched mineral used in the treatment of overweight.

Selenium is crucial for thyroid functioning.  Try eating one or two brazil nuts each day– they are supposed to be better supplements than the pills themselves.

B vitamins
Vitamins B2, B3, B5 and B6 are particularly useful for controlling weight, and here’s why: Vitamin B2 helps to turn fat, sugar and protein into energy. B3 is a component of the glucose tolerance factor (GTF), which is released every time blood sugar rises, and vitamin B3 helps to keep the levels in balance. Vitamin B5 has been shown to help with weight loss because it helps to control fat metabolism. B6 is also important for maintaining hormone balance and, together with B2 and B3, is necessary for normal thyroid hormone production. Any deficiencies in these vitamins can affect thyroid function and consequently affect the metabolism.

The B vitamins are also essential for the liver to convert your ‘old’ hormones into harmless substances which can then be excreted from the body.

Unfortunately, because our soil has been depleted by overfarming, there is very little natural zinc found in our food. Furthermore, processing and refining strip out what little might be remaining. So no matter how good your diet, you may not be getting anywhere near the levels of zinc that you need. There are two approaches to this: you can eat whole organic food, which has much more rigorous controls on farming methods, or you can add a zinc supplement to your diet. But why is it so important?

Zinc is an important mineral for appetite control and a deficiency can cause a loss of taste and smell, creating a need for stronger-tasting foods.  Zinc is necessary for the correct action of many hormones, including insulin, so it is extremely important in balancing blood sugar. It also functions together with vitamins A and E in the manufacture of thyroid hormone.

Magnesium levels have been found to be low in people with diabetes and there is a strong link between magnesium deficiency and insulin resistance.

Co-Enzyme Q10
This is a vitamin-like substance that is contained in nearly every cell of your body. It is important for energy production and normal carbohydrate metabolism.  Co-Q10 has also been proved useful in controlling blood sugar levels.

Word of mouth recommends taking boron, or eating apples, which contain boron, to boost estrogen levels, but I can’t find any scientific research endorsing this is a solid idea.


Agnus castus (Vitex/chastetree berry)
Chasteberry anecdotally helps to stimulate and normalise the function of the pituitary gland, which controls the release of LH and FSH, which signal the menstrual cycle.

Saw Palmetto (Serenoa repens) 
Saw palmetto is an herb that is traditionally considered in light of its success in treating prostate problems caused by an imbalance of hormones (including excess testosterone). It is a small palm tree found in North America and the berries of the tree are used in tinctures or capsule form.  Research has shown that saw palmetto works as an anti-androgen, which can be very helpful given the high levels of testosterone in PCOS.

Milk Thistle (Silybum marianum)
This is one of the key herbs for the liver. It helps to protect your liver cells against damage and to promote the healing of damaged cells, so improving the general functioning of the liver and all its detoxifying properties.

Spearmint tea also counts.  The mechanism is unknown, but spearmint tea has been shown to significantly reduce circulating free testosterone levels in women with hyperandrogenism.



Exercise is an excellent way to increase insulin sensitivity and promote metabolic fitness.



A great deal of healing and hormone production takes place.  During the night, when cortisol levels are low, and when the body is recharging, enables the hypothalamus and pituitary glands to send their signals to reproductive tissues uninterrupted.


Optimize thyroid function

If you have hypothyroid, or even subclinical hypothyroid, try addressing this issue before getting on different PCOS medications.  Hypo- or subclinical hypo- thyroidism os often the underlying cause of reproductive failure.  To understand more about hypothyroid and PCOS, see my recent post on PCOS pathology.   


Blood sugar medication: Metformin

Metformin is for many people a wonder drug.  Most everyone on the standard American diet I believe could take the drug and see an improvement in metabolism.  Metformin prevents the uptake of sugars in the gut, and it improves the efficiency of the insulin response, thereby creating greater insulin sensitivity and reduced testosterone levels.  Metformin is great for overweight women with PCOS who also tend to be insulin resistant.  Metformin is usually used to treat diabetes.

Metformin has also been shown to decrease testosterone levels even in PCOS patients who don’t test positive for insulin resistance.  Metformin may directly impede the production of testosterone in the ovaries.   Personally, I am a lean woman who doesn’t test positive for insulin resistance.  I took metformin for six days and ovulated for the first time in a year.


Birth control pills

Yaz, Yasmin, and Ortho-try-cyclen are popular choices.  But there’s a lot out there on birth control and I will write about the various options and implications of them all as soon as I can.  Birth control is effective in “treating” PCOS by increasing either estrogen or progesterone levels, though usually both.  However, birth control doesn’t solve the underlying issue.  In fact, many women experience even greater dysfunction in their cycles once they go off the pill.   As one popular example, some women began taking birth control as teenagers.  They continued taking it until they want to have babies, yet once they got off the pill, they found themselves breaking out for the first time in decades and unable to conceive.    Birth control pills are great for mitigating PCOS symptoms, but they will never make you more fertile, and they rarely restore hormonal balance.



Women who don’t menstruate are proscribed progesterone medications by their doctors in order to induce menstruation.   How it works is that these women take progesterone pills for ten day.  A week later, as the progesterone levels fall, estrogen levels rise, and the pituitary and ovaries read this as a signal to shed the corpus luteum.

Because amenorrhea increases the risk for endometrial cancer, amenorrheic women are advised to induce menstruation every few months.   Some go years without ill effects, and this depends on each individual’s PCOS pathology and hormone levels.  Progesterone also might help jumpstart your system back into more normal health, such that you can take it for a while and then afterwards have achieved enough of a cycle to continue functioning without progesterone. This is a good thing to do if you are trying to balance your  hormones via a more natural method, such as eliminating soy from your diet or losing weight.



 These are my favorite medications, mostly because they have served as a great crutch while I work on the rest of my issues.  Metformin is technically one of these, but other good options are spironolactone and flutamide.  Spironolactone is the safer and more efficacious of the two, so almost everyone pursues this option first.

Antiandrogens act to block or inhibit testosterone activity in the body.  For this reason, they are often proscribed for acne or hirsutism, helping women cope with these nasty issues while they try to sort out the rest of their endocrine health.

Spirionolactone, in particular, is interesting.  It is normally proscribed for high blood pressure, but it is proscribed off label to help women reduce their testosterone levels.  Spiro is shaped very similarly to testosterone, so it sits in receptor sites and blocks activity.  This is why it’s so effective against acne.  Additionally, it helps prevent testosterone production itself by inhibiting 17α-hydroxylase and 17,20-desmolase, which are enzymes in the testosterone biosynthesis pathway.

With Spiro, estrogen levels increase via enhancing the peripheral conversion of testosterone to estradiol and by displacing estradiol from sex hormone-binding globulin (SHBG).  Spiro actually decreases serum testosterone and increases serum estrogen levels.  I really can’t speak more highly of it.  The one great issue is that it creates birth defects, since testosterone is completely blocked, so Spiro absolutely cannot be taken during pregnancy.

Perhaps most importantly, Spiro has an excellent success rate with getting women to ovulate.   In this study, 11 out of 13 women began ovulating after a few months of treatment.

Spiro decreases testosterone activity in the body.  For this reason, it is an excellent treatment for hyperandrogenic symptoms such as hair loss and hormonal acne.


Ovarian Drilling

        Ovarian drilling is exactly what it sounds like—in this course of treatment, a woman lays on a table and a doctor inserts a microdrill through her abdomen and into the ovaries, creating tiny holes.  These holes puncture the thick endometrium of amenorrheic women and reduce testosterone production.  Ovarian drilling to me seems like a great option, but the complications if something goes wrong include permanent infertility.  For this reason, many people leave this option as a last resort.


For more information on PCOS, I would direct you first to Pubmed, to the Journal of Endocrinology, and also to some PCOS support forums such as soulcysters.net or www.hormonehelpny.com.

A final relevant point is that OB/GYNs are decent doctors for PCOS, but the best specialist to see is a reproductive endocrinologist.   This is my personal area of expertise, but I cannot provide you with the full range of testing that certified reproductive endocrinologists can.

I’ve read a lot about PCOS, but not everything, and this is really a summary of everything, more or less, that I’ve discovered.  In any case, my hope is you’ll hop on google and figure out how to tailor my starting points to your own needs.  That has been my greatest lesson with PCOS.    It’s all about experimentation, your own body, diligence, and patience.   

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01 2012

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  1. Sarah V. #

    Great post Pepper! Spearmint tea will now be a regular drink for me. You missed one therapy you might not known of. Cold water therapy has been shown to help fertility. I keep trying to take a cold shower, but can’t seem to get more than my head and one shoulder and arm wet before I’m freezing and can’t take it anymore.

  2. Nuka #

    Hi Pepper!

    Just found your blog, excellent work, super interesting! I’ve been on a paleo diet for over two years and never had any weight problems. I’ve always exercised a lot. I went low carb years ago.

    When I went totally paleo in 01/10, I first lost a little weight which I was happy about. BUt after four months I started to gain super fast! I ended up 13 kgs heavier and I still am. I suspect that my body was starving; I wasn’t hungry and mostly ate veggies and meat. I ate zero carbs plus I exercised excessively (as I’ve done for a loooong while). When I first started to put on weight I panicked and ate even less, exercised more and IF’d, even tho I was a wreck.

    Now, 1,5 years later I’m still at the heavier weight and I’ve just added rice to my diet two months ago. I’ve been on a low carb because it has been psychologically too hard to add carbs when I was on a low carb for so long. But now I’ve done it. So far, I feel better and don’t get this on-going hunger, but my weight is still up. :-(

    In the summer I also has PCOS diagnosed; my period has been absent for 1,5 years after I quit the pill (with which I didn’t have a period neither – a minipill). I did have cysts in my only ovary (other one was ate by a cyst when I was 17 and the cyst was removed). Still, my androgens were even too low, not high. As well as my estrogen. I don’t have any excess body hair or severe acne.

    The best news: four months ago I got my FIRST NATURAL period almost ever after taking progesterone two months before (when I also got my period but not naturally, obviously) and I’ve since had another period after two months! My gynecologist called me two days ago and when I told her this, she said that I no longer have the syndrome. I’ve heard that also the cysts may disappear really fast and other people can have them as well, not just with the syndrome. So I don’t know about the cysts.

    I’m also on thyroid medication, T3 only.

    Oh well, a long comment, should have emailed this probably. Still, happy to find you and if you have any ideas on what I should do, please share! I’m not thin nor overweight (BMI 25-26), but I am TOO FRICKIN’ big for myself! Always been smaller. Otherwise I’m good to go but I really, really want to lose the weight. Now eating paleo + white rice (also rice cakes, rice noodles). So, suggestions are welcome :-) I’m gonna comb trough all your posts!

    Thanks a million!

    • pepper #

      Sounds as though you’re on the right track with your natural hormones! I’d keep doing as you are doing right now, personally. Your doctor seems to know what she is doing. I’ve heard a lot about women who are amenorrheic after stopping taking the pill. I don’t think its TOO unusual for it to take more than a year to come back. And what I mean by that is, you’re not the first person I’ve heard say that.

      Also I am sure the T3 is helping!

      If you want to lose weight, and think about food less… well, I have a lot of things to say about that, haha. I think fasting is a great tool. I also am 100 percent behind the idea that calories matter. There’s a lot of chatter in the blogosphere right now over an article that came out in the New York times about losing weight. Basically it said that people who lose weight, and, for example, get to 120 pounds, have to eat hundreds of fewer calories per day than someone who was always or was “naturally” at 120 pounds. They also report feeling hungrier. So this might… I don’t know. It’s hard to lose weight sometimes, especially in women with hormone and thyroid problems.

      I also think low carb is best for weight loss, personally. I see you’ve tried that before, or are doing it now, so that is 100 percent up to you and your body. What works best for me isn’t necessarily what works best for you. Important things to consider are how long you’ve had this relationship with food, how “psychological” you think the problem is, whether or not you can fix is that way, or if diet really is the only piece of the puzzle missing. Both elements are very important.

      FINALLY, if I were you, I would keep doing exactly as you are until your periods become more regular. Fix one things at a time, you know? I know it’s hard, and it takes a lot of patience, but don’t worry. This is an amazing step you’ve taken with your health! I”m so happy about your natural periods. So relax into solving that puzzle, and then maybe the weight will come a bit easier.

  3. Nuka #

    Hi Pepper and thank you for your reply!

    I also think that I’ll just try to lay low and keep doing this so that I will get my period back to more normal. Meanwhile I’ll try not to put on any more weight and if possible, even lose some… Not sure if that is but have to believe in it not get hopeless.

    I think that because extremely low carb probably led me to this (ketogenic) I can’t go too low on my carbs. Hence the rice (which by the way is an advice given me by Paul Jaminet from The perfect health diet). But even with rice my carbs are pretty moderate; about 100grams per day. Have to count some calories to check it again, tho.

    I’ve actually got a doctor for my thyroid, my gynecologist hasn’t really done anything and then there are people like Jaminet who are giving me advice. I’ve also read everything by Chris Kresser (naturally) but those thyroid things don’t seem to apply to me, my etiology is different.

    It’s really interesting that you are on the side that calories matter. And in a sense, I am too. But I am certain that the hormones are the ones that make us eat or act as they do and if one wants to affect calorie intake one should address the hormonal issue. It’s not due to willpower.

    And as I said, eating very little (low carb) didn’t help me to shed this weight but it just kept piling on on minimal calories. Now I eat maybe 1600-1800kcal per day. So I guess it’s somewhere in the middle for me regarding carbs.

    Oh well, I don’t know what to tweak next… But maybe I just need to add some T4.

    Anyway, great to get to talk to you, I’ll be back. :-)

    • pepper #

      Hah, NO, T3 is lightyears better than T4. Stick to your endocrinologist’s guns. :)

      I agree with you totally– hormones are primary. The thing is, no matter what our hormones are doing, the calories we eat matter. They can make it easier or harder to eat more or less, and also effect general function, of course, but their influence is primarily that: an influence. So I think, for example, that if we are hungry all the time, this doesn’t give us license to eat non-stop. I see a lot of people “misinterpret” this. It definitely means something is wrong, but its going to take some serious thinking and experimentation to figure out just where in the process the disconnect is happening.

      Which I guess is what you and I are both trying to do.

      I think you’re doing great, don’t sweat it, the Jamninets are awesome and I recommend them more highly than myself, naturally. Of course, they’re also not specialists in women’s health, so I’d keep that in account too and always check it against whatever literature, experience, anecdotes, etc, you can find.

      Or something.

      • pepper #

        All that said, I’ve been wondering for a long time, and I’m still really curious: what is the area of overlap between disordered eaters and those with metabolic syndrome? Or with disordered eaters and those with PCOS? I wonder often if serotonin dysregulation, or stress, both of which lead to endocrine malfunction, are the underlying cause of all of these issues.

  4. Nuka #

    I hear you about the calories and sort of agree, naturally they do have an influence. But it’s not as simple as to just “not eat” when your body is screaming for food. I’m not saying to use it as an excuse, but I’m saying, that even the best of us are quite powerless against hormonal things. I wish everyone with these kinda of problems (like, almost everyone in the Western world ;-) ) would know that it’s not their fault and it can be changed. To say that it’s not someone’s fault isn’t a free pass to just gorge down anything. I think the guilt felt about eating this or that or this much or that little is the worst thing and only causes pain and suffering.

    Oh yes, would be interesting to get a picture of those overlapping conditions! Everything’s so fu*king related ;-D Sometimes I just get so tired of it, tho it’s brilliant :-) And I’m not considering myself as a disordered eater even if I went a bit over board with paleo and low carb, I was just…. Stupid?

    • pepper #

      YES. When I say “disordered eater” I generally mean “people who can’t stop thinking about food and are always hungry or eating.” I think that that speaks to hormonal derangement, hugely, but I have no idea how to go about fixing it or even thinking about fixing it.

  5. K #

    Hey! Welcome back, glad I stopped by here to check in on whether you had any new insight.

    I had a semi breakthrough this summer with my PCOS: I thought I was a thin PCOS-er, but turns out after I lost an additional 5 lbs by running to catch the train with heavy bags every day, and simply eating less , I got my period 1 month apart instead of the usual two (turns out I’ve been bloated my entire life?! and that combining certain foods together, but not eating them separately causes this, and that I was overeating on healthy food). But only that one time. My BMI (poor way to measure, but still) was 19 (I’m 5’7, 122 lbs) when I realized that I was still overweight, especially in the stomach, for my frame.

    One herb my grandma pushed on me was some sort of inula (commonly used in Russia for menstrual stuff), which also gave me my period 1 month apart on another recent occasion, but more recently with the holidays I’ve been less disciplined with everything, so I’m not surprised that the results didn’t last.

    I’d also like to put a plug in for ayurveda. I’m all for evolutionary medicine/eating like ancestors, but ayurveda has a lot to offer for disorders of fertility, and herb supplementation is just 5% of it. approach varies depending on your body type. I’ve realized that most dietary conclusions that I’ve come to for optimizing my mental/physical potential in the last few years are recommended by ayurveda for my body type.

  6. Rachel #

    I’m shocked that you’re telling thin pcos women to eat “lots” of carbs. Insulin resistance and pcos go hand in hand in most cases, and being a thin pcos’er I with significantvinsulin resistance and reactive hypoglycemia I can tell you that, yes, it happens, and more often than you probably realize.
    Eating carbs of any sort, especiallg without protein and fats addes to the meal, causes significant insulin production, which is a no-no for someone with insulin resistance. It will not only encourage weight gain, but will perpetuate insulin resistance, pcos symptoms (ovaries are sensitive to insulin and stimulate production adrogenistic hormones), and promote diabetes in the future.

    You should really do more research and/or correct this bit of advice to avoid harming those who find your site looking for help.

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