Polycystic Ovarian Syndrome (PCOS): Understanding the Root Causes

Polycystic Ovarian Syndrome (PCOS) affects millions of women and is one of the most common endocrine conditions worldwide. But PCOS is more than just an ovarian issue. It’s a metabolic and hormonal imbalance that can impact your skin, hair, cycles, weight, and long-term health. The good news? By addressing the upstream causes, you can restore balance and reduce symptoms.

Upstream Causes of PCOS

Insulin Resistance

Most women with PCOS struggle with insulin resistance.  Insulin resistance occurs when cells don’t respond properly to insulin, leading to high blood sugar and higher circulating insulin levels. This excess insulin drives the ovaries to produce more androgens (male-type hormones), leading to:

• Irregular ovulation and cycles
• Acne and excess facial/body hair
• Central weight gain and sugar cravings

5-Alpha Reductase Metabolic Preference

Some women with PCOS convert more testosterone into dihydrotestosterone (DHT) through the enzyme 5-alpha reductase. DHT is a much stronger androgen that binds tightly to hair follicles and oil glands.

• Results in cystic acne, scalp hair loss (androgenic alopecia), and hirsutism.
• This explains why some women with normal testosterone levels still experience significant symptoms.

Metabolic Syndrome

 Over time, PCOS increases the risk of metabolic syndrome, which includes:

• High blood pressure
• High triglycerides and low HDL cholesterol
• Elevated blood sugar
• Central obesity

These changes raise lifetime risk for type 2 diabetes and cardiovascular disease, highlighting the importance of proactive management.

How to Talk to Your Provider About Testing for PCOS

One of the biggest challenges women with PCOS face is getting the right diagnosis. Because PCOS can look different in every woman, it’s important to have clear conversations with your provider. Here’s how to approach it:

Share Your Full Symptom Picture

Don’t just talk about irregular cycles — mention all of your symptoms, such as acne, hair thinning, weight changes, fatigue, or mood shifts. The more complete the picture, the easier it is for your provider to connect the dots.

Ask About Key Lab Tests

While there’s no single “PCOS test,” labs can help rule out other causes and identify hormonal patterns. Ask your provider about:

• Fasting glucose and insulin – for insulin resistance

• Hemoglobin A1c – longer-term glucose control

• LH and FSH – to assess ovulatory hormone patterns

• Total and free testosterone – often elevated in PCOS

• DHEA-S – another androgen source (adrenal gland output)

• Sex hormone binding globulin (SHBG) – may be low in PCOS, leading to higher free testosterone

• Progesterone and Estradiol (day 21 of cycle, if cycles are regular) – helps check for ovulation and evaluates estrogen dominance relative to progesterone level

• Thyroid panel (TSH, free T4, free T3) – thyroid issues can mimic PCOS

• Prolactin – to rule out pituitary causes of irregular cycles

Ask About Imaging

A pelvic ultrasound may be ordered to check for the presence of multiple small ovarian follicles (“cysts”), but not every woman with PCOS will show this finding.

Questions to Ask Your Provider

• Could my symptoms be related to PCOS?

• What other conditions do you need to rule out?

• How do my labs support or rule out PCOS?

• How can we track progress beyond just symptom relief?

Advocate for Yourself

If you feel dismissed, don’t hesitate to ask for a second opinion. PCOS is a lifelong condition that can affect fertility, metabolism, and overall health.  You deserve thorough testing and ongoing support.

Pro tip for patients: Bring a written list of your symptoms, menstrual history, and questions to your appointment. This keeps the visit focused and ensures your concerns are heard.

Balancing Lifestyle and Hormones: Nutrition and Lifestyle Foundations 

Diet

Food is one of the most powerful tools for PCOS.

• Pair protein and healthy fats with every meal to prevent insulin spikes.
• Choose low-glycemic carbs such as lentils, quinoa, and berries.
• Eat plenty of fiber-rich vegetables to support satiety and hormone metabolism.
• Limit refined sugar, white flour, and processed foods especially if you have prediabetes, elevated fasting insulin, or elevated triglycerides as this points to an increased risk for future Type 2 Diabetes.

Lifestyle

• Exercise: Strength training improves insulin sensitivity and helps balance hormones. Aim for 30 minutes most days.
• Sleep: 7–9 hours nightly helps regulate cortisol and appetite hormones.
• Stress management: Yoga, meditation, and deep breathing help reduce cortisol spikes that worsen insulin resistance.
• Cycle tracking: Monitoring ovulation can help you and your provider evaluate progress.

Progesterone Optimization

Because many women with PCOS do not ovulate regularly, progesterone production is often low. This can contribute to:

• Irregular cycles
• PMS/PMDD symptoms
• Insomnia and anxiety

Supporting ovulation through lifestyle and insulin balance naturally boosts progesterone. In some cases, bioidentical progesterone therapy may be appropriate under medical supervision.

Targeting Acne, Hirsutism, and Alopecia

• Lowering insulin helps reduce androgen production at the source.
• Blocking DHT (with herbs like saw palmetto) protects hair follicles and oil glands.
• Topical care (azelaic acid, niacinamide, retinoids) can help acne externally.
• Hair removal treatments (laser or electrolysis) can manage persistent hirsutism once hormones are more balanced.  Topical prescription medications like eflornithine hydrochloride can reduce hair regrowth with regular use.

Supplement Support for PCOS

These evidence-informed supplements can support insulin regulation, androgen balance, and cycle health. Always consult your provider before starting new supplements.

• Inositol (NOW Foods Inositol Powder): Improves insulin sensitivity, ovulation, and egg quality. Affordable and well-studied.
• Berberine (Endurance Dihydroberberine): Supports healthy blood sugar and lipid balance. Dihydroberberine is highly bioavailable.
• Agobi Premium Saw Palmetto*:
• 5-Alpha Reductase Inhibition: Blocks the enzyme converting testosterone to DHT, reducing acne, hirsutism, and hair loss.
• Anti-Androgenic Effects: Decreases DHT binding to skin and hair follicles.
• Anti-Inflammatory: Helps calm acne-prone skin.
• Standardized for active fatty acids and sterols, ensuring potency and consistent results.
• Testoquench*: A professional blend of herbs that lowers excess androgens to support clearer skin and reduced hirsutism.
• PCOPx*: Combines inositol, antioxidants, and hormone-balancing nutrients specifically for PCOS support.
• Magnesium glycinate: Helps with insulin regulation, stress resilience, and sleep.
• Zinc (NOW Foods Zinc Picolinate): Supports ovulation and reduces acne; often low in PCOS.
• Vitamin D3 + K2: Supports hormone regulation, bone strength, and immune health.
• N-Acetylcysteine (NAC): Improves insulin sensitivity and has antioxidant effects.
• Spearmint and Stinging Nettle Tea: Simple, affordable option shown to reduce free testosterone and hirsutism with daily use.
• Vitex and prescription topical progesterone products:  Vitex (chasteberry) supports the pituitary gland to gently boost progesterone relative to estrogen, helping ease estrogen dominance. Topical progesterone cream adds progesterone directly, restoring balance and reducing symptoms like bloating, breast tenderness, and mood changes.

*Agobi, Testoquench and PCOPx all have overlapping ingredients so only choose one of these products and make sure to account for overlaps with all and any supplements you add to your program.

Pharmaceutical Options for PCOS

While lifestyle, nutrition, and supplements address upstream causes, some women may prefer or need pharmaceutical options. These treatments often help manage symptoms but don’t fully correct the metabolic drivers of PCOS. Still, they can provide important relief, especially when symptoms are severe or when contraception is also desired.

Oral Contraceptive Pills (OCPs)

• How they work: OCPs contain estrogen and progestin, which regulate cycles, reduce androgen production from the ovaries, and increase sex hormone-binding globulin (SHBG). Higher SHBG binds up free testosterone, reducing acne and excess hair growth.
• Benefits:
• Cycle regulation
• Improved acne and hirsutism
• Reliable contraception
• Considerations:
• OCPs do not resolve insulin resistance or metabolic risks.
• Some women experience mood changes, headaches, or weight fluctuations.
• Discontinuation often leads to return of PCOS symptoms if root causes aren’t addressed.

Spironolactone

• How it works: Spironolactone is a mild diuretic with anti-androgen effects. It blocks androgen receptors in the skin and reduces 5-alpha reductase activity, lowering the effects of testosterone and DHT at the hair follicles and oil glands.
• Benefits:
• Reduces acne
• Decreases unwanted facial/body hair
• Slows progression of androgenic alopecia
• Considerations:
• Does not provide contraception on its own. Because spironolactone can affect a developing male fetus, it must be paired with reliable birth control.
• Common side effects: increased urination, breast tenderness, menstrual irregularities, or low blood pressure.

Fertility Considerations

It’s important to note that having PCOS does not mean you are infertile. While ovulation may be irregular, spontaneous ovulation and pregnancy are still very possible. Women with PCOS should always use contraception if they are not trying to conceive, since unplanned pregnancy can and does occur.  If you are trying to conceive, make sure to add a quality prenatal vitamin with L5MTHF folate to best support your pregnancy.

The Bottom Line

PCOS is not just a reproductive condition, it’s a whole-body metabolic and hormonal syndrome. The root causes often lie in insulin resistance, inflammation, and androgen excess. By combining nutrition, lifestyle changes, hormone support, and targeted supplements like inositol, berberine, and Saw Palmetto, women can significantly reduce symptoms and protect long-term health.

Pharmaceutical options like OCPs and spironolactone can be effective tools for managing symptoms, especially when contraception is also needed. The most empowering approach is individualized: blending root-cause strategies with medications when appropriate, so each woman can find the balance that fits her health goals and lifestyle.

Disclaimer:  The information on this blog is for general informational purposes only and does not constitute medical advice. Do your own research and consult with a qualified healthcare professional for any health concerns or before making any decisions related to your health or treatment.  Use supplements thoughtfully and at your own risk.