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PCOS in Teens

December 3, 2018
PCOS in teens, toronto naturopath, naturopathic doctor toronto, teen naturopath, danforth naturopath

Experiencing acne?

Missing a period or two?

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in reproductive-aged women including teens! Now before you roll your eyes and utter the sentence, “I don’t have cysts on my ovaries,” please note you don’t need to have cysts in order to have PCOS (I’ll talk about that below). 

PCOS is a collection of symptoms – both visual (like acne) and diagnostic (like serum testosterone). It’s also a diagnosis of exclusion among other androgen (male hormone) excess disorder. In teens, PCOS may present differently than it would in adults. 

PCOS Criteria in Teens

To be diagnosed with PCOS, you must have 2 out of 3 criteria, as defined by the Rotterdam Criteria. Criteria includes:

  1. Delayed ovulation or irregular menstrual cycles (anovulation)

  2. High androgenic hormones like testosterone

  3. Polycystic ovaries on ultrasound

In teens however, both irregular menstrual cycles and hight androgens are required. Ultrasound is not recommended for diagnosis. 

High Androgens (aka. hyperandrogenism)

What’s are androgens? It’s a group of male hormones which are present in females. The most common one is testosterone. When androgen levels are high in the body, it can lead to some unwanted symptoms.  

High androgens are the most common criteria seen in teens, because it includes clinical signs like acne and/or hirsutism (male-pattern hair growth) – caused by, you guessed it, high testosterone levels. 

But, just because you see a couple of zits or see some hair – it doesn’t mean you have PCOS. 

We’re talking about moderate-severe acne (ex. more than 11 red zits on your face) that isn’t affected by topical medications. When it comes to hair, you need to score between 4-6 on the modified Ferriman-Gallwey chart. One thing to note is that some ethnicities present with more hair growth, which should be factored in when calculating the score. 


PCOS, toronto naturopath, naturopathic doctor toronto

Source: https://pedclerk.bsd.uchicago.edu/page/hirsutism

You may also notice hair loss, around the frontal area (ie. where your bangs would be), and that can also be a sign of high testosterone.

Another way to determine if you have high androgens (like testosterone) is by testing them. A simple blood test will suffice (no need for the fancy tests) and can be done anytime during your cycle. Shortly after your period begins, serum testosterone reaches adult levels. 

Androgens that you may want to get tested include:

  • Total testosterone

  • Free testosterone

  • DHEA

  • Androstenedione

  • Sex Hormone Binding Globulin

Irregular Periods

Period length can actually vary based on when you first experience menstruation. Irregular cycles are defined as:

  • Normal in the first year of having your period

  • In the first 1-3 years of having your period: Less than 21 or greater than 45 days

  • After having your period for 3 years: Less than 21or greater than 35 days

  • After having your period for 3 years: Less than 8 menstrual cycles per year

Moreover, when you first start getting your period, it’s highly likely that you won’t be ovulating. Approximately 85% of menstrual cycles (in the first year of your period) are ovulatory. Six year in, only 25% of your cycles will be anovulatory (aka. no ovulation is happening).  

Within the first 2 years after your period starts, you may notice period irregularities and anovulation – and that’s okay!

Polycystic Ovaries

In case you missed it, you don’t need to have polycystic ovaries to have PCOS. In fact, the ASRM guidelines state that ultrasound should not be used for diagnosis in women who have had their period for less than 8 years because ovaries tend to have lots of follicles during this time. 

So what does that mean? You need to rely on the other 2 criteria to figure out if you have PCOS. 

Conventional Treatments of PCOS

It’s likely that if you go to your medical doctor, they’ll tell you to take the birth control pill. The pill is considered the first line of treatment. You may hear that the pill will regulate your cycle, but it will actually shut down your body’s natural hormones and replace them with the hormones in the pill – which may be a synthetic estrogen and progestin (depending on which you take). Periods that you experience while on the pill, aren’t true periods at all – they are simple withdrawal bleeds from the hormones. 

Here’s the thing. If you think of the pill as a bandaid, you won’t know if these symptoms are just going to come back once you stop the it. Most women stop the pill around the time they’re ready to start thinking of having kids. But if PCOS is still looming in the background, it may lead to fertility issues down the line. 

Something that you should also be aware of is that severe anxiety and depression is higher in adults with PCOS. And it’s likely also increased in teens. A huge study in 2016 investigated different types of birth control and how they were associated with antidepressants and a diagnosis of depression. Researchers found that teens (between 15 to 19) are more sensitive to depressive symptoms and antidepressants than adults. This was seen when teens were using the combined pill and progestin-only pill. The study did show that the incidence of depression and antidepressants use decreased with age. 

Birth control is not always bad, it’s provided choice and reproductive freedom to many, but it’s important to recognize why you’re taking, and understanding the risks associated with it as well. 

Approaching PCOS Naturally

When we’re dealing with PCOS in teens we want to do a couple of things:

  • Promote a regular menstrual cycle

  • Restore natural ovulation

  • Reduce/get rid of acne and hirsutism

  • Achieve weight loss if necessary (because this may lead to conditions like diabetes)

Yes, there are supplements you can take to help with the above four goals. But one of the main priorities is to promote a healthy diet and exercise in ALL teens with PCOS. I go into that more in previous articles, so please check those out. These have widespread effects in optimizing hormonal outcomes, general health and quality of life.  

This doesn’t mean you should be eating salads and hopping on a treadmill ASAP though. It’s important to take stock of your daily or weekly routine and see which changes can be made. Making some goals, writing things down (ex. a diet and exercise diary, as long as it’s not leading to eating disorder tendencies), problem solving with a parent or health professional, etc. 

Taking things slow is okay. Starting small is okay. One of my favourite quotes (that I usually see when I make a cup of tea) is “The creating of a thousand forests is in one acorn.”

Exercise and PCOS

Exercise guidelines are different between adults and teens. You should be aiming for at least 60 minutes per day of moderate to vigorous intensity physical activity, including activities that strengthen muscle and bone at least 3 times weekly. Group classes can be helpful, because of the social and community aspect. 

Examples of exercises that specifically strengthen muscle and bone are:

  • Dancing

  • HIIT workouts 

  • Hiking

  • Jogging/running

  • Jumping Rope

  • Stair climbing

  • Tennis

For more info on exercise and PCOS, check out my previous article here

Next Steps

Now that you’re familiar on how PCOS is presented in teens, here’s what you can do next:

  • Track your cycle length

  • Pay attention to any clinical signs, such as acne or hair growth

  • Get your blood work done (PS. NDs can order your blood work too!

Once you have these, figure out how you want to approach the solution. Will it be birth control or focusing on the root of the issue?

Now that you have a solid plan, please sign up for my monthly newsletter called The Flow for more informative and useful content like this! I want to make sure that you have a good flow!

References

Teede, H., Misso, M., Costello, M., Dokras, A., Laven, J., Moran, L., Piltonen, T., Norman, R., Andersen, M., Azziz, R., Balen, A., Baye, E., Boyle, J., Brennan, L., Broekmans, F., Dabadghao, P., Devoto, L., Dewailly, D., Downes, L., Fauser, B., Franks, S., Garad, R., Gibson-Helm, M., Harrison, C., Hart, R., Hawkes, R., Hirschberg, A., Hoeger, K., Hohmann, F., Hutchison, S., Joham, A., Johnson, L., Jordan, C., Kulkarni, J., Legro, R., Li, R., Lujan, M., Malhotra, J., Mansfield, D., Marsh, K., McAllister, V., Mocanu, E., Mol, B., Ng, E., Oberfield, S., Ottey, S., Peña, A., Qiao, J., Redman, L., Rodgers, R., Rombauts, L., Romualdi, D., Shah, D., Speight, J., Spritzer, P., Stener-Victorin, E., Stepto, N., Tapanainen, J., Tassone, E., Thangaratinam, S., Thondan, M., Tzeng, C., van der Spuy, Z., Vanky, E., Vogiatzi, M., Wan, A., Wijeyaratne, C., Witchel, S., Woolcock, J. and Yildiz, B. (2018). Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Fertility and Sterility, 110(3), pp.364-379.

Peña, A. and Metz, M. (2017). What is adolescent polycystic ovary syndrome?. Journal of Paediatrics and Child Health, 54(4), pp.351-355.

Rothenberg, S., Beverley, R., Barnard, E., Baradaran-Shoraka, M. and Sanfilippo, J. (2018). Polycystic ovary syndrome in adolescents. Best Practice & Research Clinical Obstetrics & Gynaecology, 48, pp.103-114.

PCOS and Exercise

Written by   in 
September 24, 2018
PCOS and exercise, toronto naturopath, naturopathic doctor toronto

We all know that exercise is helpful in general, and that is especially true for those living with PCOS. Exercise may improve ovulation, insulin resistance and promote weight loss. Yet, it’s hard to say which type of exercise, the intensity, and how much PCOS-ers should be doing.  

Types of Exercise

Resistance Training

Resistance training (also known as weight or strength training) requires the body (muscles) to push against force that is practised against it. This includes bodyweight exercises, plyometrics, use of resistance bands, free weights or machine equipment. Resistance training is thought to be beneficial to PCOS-ers because it can improve insulin resistance, glucose metabolism and resting metabolic rate, lowers body fat and increases lean muscle mass. 

One study looked at progressive resistance training in women with PCOS. Women in the intervention group exercised for 1 hour per day, 3 times a week for 4 months. Exercises included: bench presses, leg extensions, front lat pull-downs, leg curls, lateral raises, leg presses (45 degrees), triceps pulleys, calf leg presses, arm curls, and abdominal exercises executed in alternating segments. At the end of this study, the women with PCOS experienced weight loss and increased muscle mass, lowered androgen levels, increased reproductive function, but no significant changes to insulin resistance.  

The 2015 Almenning study also evaluated strength training compared to HIIT in women with PCOS, and also found that at the end of the study while there was an improvement in body composition, there were not any changes to insulin resistance. 

Aerobic Exercise

A 2018 study looked at aerobic exercise in women with PCOS. Participants performed 40 minutes of exercise (including 5 minutes of warm up and 5 minutes of cool down), 3 times a week for 16 weeks. The exercise group completed their supervised exercise outside on a track. Interestingly enough, the study does not explicitly state what exercise the control group did, however it may have been unsupervised exercise for 150 minutes per week (this is what I am guessing).

Results demonstrated that there was an improvement in the health-quality of life score, an improved cardiometabolic profile, reduced BMI and waist circumference, and overall positive response doing exercise. However, no changes were seen in fasting glucose or insulin or HOMA-IR values in both control and exercise groups. 

High Intensity Interval Training (HIIT)

In men with insulin resistance, studies have shown that HIIT has had a positive impact overall, compared to continuous training (think walking or running). 

One study looked  at HIIT in women with PCOS. These women participated in a 10-week program where they would do HIIT three times a week. Two sessions were 4×4 minutes of HIIT at 90-95% of their maximum heart rate, separated by 3 minutes of moderate intensity exercise around 70% of their maximum heart rate. The last session was 10×1 minute of maximum intensity HIIT separated by 1 minute of rest or low activity. Mode of exercise was dependent on the individual, but could be the treadmill, outdoor walking/running/cycling. The control group were simply advised to do at least 150 minutes of moderate-intensity exercise per week.  

The primary outcome of this study was to measure the change in insulin resistance (via the HOMA-IR value) from baseline to post-intervention. In the group who did HIIT, IR values significantly improved (specifically fasting insulin), as well as overall body composition. 

PCOS and yoga, toronto naturopath, naturopathic doctor toronto

Yoga

So far the only studies looking at the effect of yoga on PCOS, have been done in adolescent girls. In previous studies, yoga has been studied in men and with poor insulin sensitivity as well as in people with obesity and diabetes.  

A 2012 study looked at adolescent girls and the effects of yoga on glucose and insulin levels. Girls were divided into 2 groups – 1 which practiced yoga (1 hour a day for 12 weeks), and the other which practiced conventional physical exercises. At the end of the 12 weeks, there was reduction in fasting blood glucose in the yoga group as well as a drop in the HOMA-IR score of 0.38. The control group actually had an increase in their HOMA-IR score of 0.29. 

A 2013 study by the same authors looked at the effects of yoga in adolescent women, but this time specifically looking at endocrine parameters (Anti-mullerian hormone (AMH), luteinizing hormone (LH), follicle stimulating hormone (FSH), testosterone, prolactin, body–mass index (BMI), hirsutism, and menstrual frequency) before and after 12 weeks. Adolescents in the yoga study practiced for 1 hour per day for 12 weeks, while the other group simply practiced conventional physical exercises. At the end of the 12 weeks, they found that yoga was better at reducing AMH, LH, and testosterone and improving menstrual frequency. 

Final Thoughts

You obviously have your pick when it comes to exercise. I would choose something based on what you like to do (if you hate yoga, don’t do it) and what your goals are. I personally want to decrease my HOMA-IR value, so choosing HIIT and yoga might be the way to go for me. 

Something important to keep in mind is that exercise is not the be-all and end-all of treatment. In fact, doing too much exercise may impair your adrenal glands, causing more inflammation, thereby causing more insulin resistance. Sometimes taking it easy is key, and doing gentle exercises (ie. walking, yoga) will your best bet in your path of healing. 

Exercising Tips

One of my favourite authors, Gretchen Rubin, has some tips when it comes to sticking with exercise. Some of my favourites are:

  • Plan exercise with a friend who will not be happy if you don’t show up

  • If you’re travelling, figure out how you will schedule in some exercise

  • Keep track of how much you exercise (ie. I put stickers on my recycling calendar)

  • Pair activities (ie. Watching Netflix? Exercise at the same time)

If you found this information helpful, please sign up for my monthly newsletter called The Flow for great and informative content like this!

References

KOGURE, G., MIRANDA-FURTADO, C., SILVA, R., MELO, A., FERRIANI, R., DE SÁ, M. and REIS, R. (2016). Resistance Exercise Impacts Lean Muscle Mass in Women with Polycystic Ovary Syndrome. Medicine & Science in Sports & Exercise, 48(4), pp.589-598.

Almenning, I., Rieber-Mohn, A., Lundgren, K., Shetelig Løvvik, T., Garnæs, K. and Moholdt, T. (2015). Effects of High Intensity Interval Training and Strength Training on Metabolic, Cardiovascular and Hormonal Outcomes in Women with Polycystic Ovary Syndrome: A Pilot Study. 
PLOS ONE, 10(9), p.e0138793.

COSTA, E., DE SÁ, J., STEPTO, N., COSTA, I., FARIAS-JUNIOR, L., MOREIRA, S., SOARES, E., LEMOS, T., BROWNE, R. and AZEVEDO, G. (2018). Aerobic Training Improves Quality of Life in Women with Polycystic Ovary Syndrome. Medicine & Science in Sports & Exercise, 50(7), pp.1357-1366.

Nidhi, R., Padmalatha, V., Nagarathna, R. and Ram, A. (2012). Effect of a yoga program on glucose metabolism and blood lipid levels in adolescent girls with polycystic ovary syndrome. International Journal of Gynecology & Obstetrics, 118(1), pp.37-41.

Nidhi, R., Padmalatha, V., Nagarathna, R. and Amritanshu, R. (2013). Effects of a Holistic Yoga Program on Endocrine Parameters in Adolescents with Polycystic Ovarian Syndrome: A Randomized Controlled Trial. The Journal of Alternative and Complementary Medicine, 19(2), pp.153-160.

PCOS and Insulin Resistance

Written by   in 
September 17, 2018
pcos, insulin resistance, naturopathic doctor toronto, toronto naturopath

Now that you are familiar with PCOS and the four types, it’s time to talk about insulin resistance – one of the underlying causes of this syndrome.

What is insulin resistance?

Insulin resistance happens when the cells in the body do not respond normally to insulin.

Insulin, a storage hormone, is produced by the pancreas, in response to whenever we eat food. Insulin will cause the liver and muscle cells to take in glucose/amino acids/fat from the bloodstream (where they will convert it into energy), and this process will ultimately lead to lowered blood sugar and insulin.

When someone is insulin resistant, glucose has a difficult time entering the cell, so it hangs out in the blood for much longer. More insulin is released to push glucose into the cell, causing metabolic dysfunction. Typical symptoms include fatigue after eating, sweet cravings no matter how many sweets you eat, increased thirst and urination.

When someone is insulin resistant, your body needs to make more insulin to get the job done. Too much insulin can cause both inflammation and weight gain which may end up leading to metabolic syndrome – diabetes and cardiovascular disease. In women, insulin resistance may affect ovulation, cause the ovaries to make more androgens, and affect fertility – recurrent miscarriage or inflammatory implantation failure.

Specifically, insulin stimulates testosterone secretion from the ovaries and inhibits sex hormone binding globulin production (which binds to testosterone). This leads to more testosterone in the blood stream which may account for acne, facial hair, and male pattern hair loss (top of the head). 

How to test for insulin resistance?

Although not the gold standard test, using the HOMA-IR calculation can tell you if you have insulin resistance. This test can be relatively simple – you just need 2 blood tests:

  • Fasting insulin, an optimum level less than 50 pmol/L

  • Fasting glucose

Plug these two values into the HOMA-IR calculator, to figure out your score. Ideally, you want a value less than 1.  

How to reverse insulin resistance

One of the best ways to reverse insulin resistance is to balance your blood sugar! This undoubtedly begins with food. 

Glycemic Index

The glycemic index is a marker used to calculate how quickly a particular food (50g of it) can raise blood sugar levels (over a 2 hour period) compared to pure glucose. The higher the glycemic index, the quicker the blood sugar is raised.

  • High Glycemic Index = 70 or more

  • Low Glycemic Index = 55 or less

Something to keep in mind is that foods are not alike, and neither is the serving size. This brings us to glycemic load. 

Glycemic Load

The glycemic index changes based on the amount of carbohydrates in each food and the serving size. It’s calculated by the amount of food eaten and multiplied by the glycemic index. 

  • High = GL of 20 or more

  • Medium = GL of 11 to 19

  • Low = GL of 10 or less

For example:

  • A typical serving of watermelon may be 1 cup, which has 11 grams of carbohydrates.

    • GI of 72 x 11 gram = 792. Divide by 100 = 7.92

  • A typical serving of regular crust cheese pizza may be one slice, which has 34 grams of carbohydrates.

    • GI of 33 x 34 = 1122. Divide by 100 = 11.22

Food Insulin Index

This index assesses how much insulin the body normally releases in response to food. Certain foods require more insulin, while other foods need much less. Foods with a lower FII can help lessen the insulin demand on your pancreas. 

How to choose the best balancing foods

Keeping the glycemic index, glycemic load, and food insulin index top of mind may be difficult. Let’s talk about what should be plentiful in your diet. 

Fruits & Vegetables

If half of our plate should be made up of plants, then you know that we should be eating a lot of fruits and vegetables throughout the day. Not only are they filled with great vitamins and minerals, they also have a lot of fibre (which will keep us regular!). Focusing on leafy green vegetables is key, but you can also include broccoli, cauliflower, Brussels sprouts, carrots, eggplant, mushrooms, onions and garlic (basically my entire fridge). 

But what about starchy vegetables? While these tends to have a higher glycemic index and load, you can still incorporate them in your diet, albeit in smaller amounts. Squash, sweet potatoes, beets and even white potatoes are considered starchy, but shouldn’t be eliminated from your diet. 

Fruits don’t need to be eliminated either, despite them obviously being high in fructose. You want to enjoy more fruits that have lower sugar – these include avocados, tomatoes, raspberries, blackberries, blueberries, strawberries (but choose organic) and lemons!

Fats

Fact: fat is good for you. But the reality is, many fats are highly processed. So which are the ones you should stick to? Avocado oil, extra virgin olive oil, coconut oil, and ghee (but choose organic, and don’t make this your primary oil).

Animal Protein

Protein (& fat) should always be part of a meal. They help to give you energy, balance blood sugar (by keeping it from spiking), and maintaining satiety. Protein is rich in amino acids which are basically the building blocks of your body. Plus, amino acids help to transport hormones and make sure your liver is detoxing properly. Fat, especially cholesterol, is essential because this is what sex hormones are made of! 

When it comes to meat, chicken is a better option than red meat (although eating it once in a while is fine). A couple of ‘labels’ to pay attention to is organic, grass-fed, hormone and antibiotic free. If you can afford to purchase meat with these labels, I encourage you to do so. However, I recognize that this is not an option for everyone (as it can be quite costly), but choosing 1-2 organic options may be the way to start (especially if you eat these on a consistent basis). 

Fish is a great protein option too, but some types can be high in mercury. Nevertheless, Wild Alaskan or Sockeye salmon, mackerel, shrimp, crab, anchovies and mussels are lower in mercury. Wild is better than farmed, which is something to keep in mind especially when buying salmon. 

Eggs should also not be avoided, especially since they’re a great breakfast food (#byecereal)! Eating eggs, in most people, will not raise your cholesterol. In fact, it may raise your good (HDL) cholesterol!

Final Thoughts

If you’ve made it to the end, thanks for sticking with me! Talking about diet and the role it plays in our health can be quite tough. Many of us don’t love overhauling our diet – after all, food plays an important role in our lives. That said, because we need to eat everyday, it’s important to pay attention to what we are putting in our mouths. 

If you think that you might be struggling with PCOS, be sure to read my past articles (what is PCOS, types of PCOS) and consider getting your blood work done.

If you found this information helpful, please sign up for my monthly newsletter called The Flow for great and informative content like this!