Understanding PCOS [Part 3: Evidenced Based Supplements]

For the past two weeks, we’ve been in a PCOS series. In Part 1 we talked about what causes PCOS, how a diagnosis is made, the different types of PCOS and what is happening in your body if you do have PCOS. In Part 2 we talked about reasonable and evidence based lifestyle modifications you can make (including many that go beyond food) to improve your PCOS…no diets involved. My hope is that these posts are informative, but they are certainly not prescriptive. Nutrition and medicine are highly individual – everyone has different genetics and biology, so it’s really important to work with your health care provider and dietitian to figure out what combination of treatment modalities will work best for you.

Everyone is at a different place in their lives so your treatment will take into consideration all those things – there is no one size fits all. The optimal treatment approach for PCOS in multifactorial – lifestyle modifications, psychological treatment, supplements, and medications all play a role. I think the most important thing is that you as the patient and woman feel empowered in your decisions, that you feel well informed on the pros/cons of everything and that you know your treatment is 100% a personal decision and whatever works for you, works for you. You are not better or worse or doing things right or wrong for choosing or not choosing something to care for yourself.

In this post, we’re going to talk about supplements that have been well researched and shown to improve PCOS. Often, supplements can be a really powerful tool in helping women with PCOS along with lifestyle changes and other treatments that might be necessary too. I’m not one who throws around supplements and suggests taking supplements just to take them. I think that can end up being really expensive and stressful. And the supplement world can get confusing very fast. While supplements are different than medications, are still powerful and change endocrine and metabolic pathways in the body; therefore it’s really important to take supplements appropriate for your body. Work with a dietitian or health care provider who is knowledgable around these supplements before taking them so you know what is best for you.

Supplements are meant to support lifestyle choices, but they certainly aren’t a replacement. Just like taking certain supplements to lower cholesterol isn’t a replacement for eating nourishing foods and moving in an enjoyable way or taking supplements to recovery from amenorrhea isn’t a replacement for giving your body the rest and nourishment it needs…same goes for PCOS. All these tools whether some of all of them – lifestyle, psychological treatment, supplements, and medications – they all play a role.

There are many more potential supplements that you can take for PCOS than what I’m going to share in this post. Some have more research than others. The ones I’m sharing below are what I would consider the basics to start with and then if things still need some tweaking after implementing lifestyle changes and other tools, you could consider trying other supplements in partnership with your dietitian and/or HCP. These ones I’m sharing below have also been well researched.

Inositol

Inositol has a large body of evidence when it comes to it’s efficacy in the treatment of PCOS. Out of 9 total, the 2 stereoisomers well researched in particular are myo-inositol and d-chiro-inositol. It’s been demonstrated that women with PCOS experience dysregulation of inositol metabolism which affects fertility, insulin and many other factors – this could actually be why women with PCOS experience insulin resistance in the first place. Research has shown that myo-inositol has the most profound effect over d-chiro, but these two sterioisomers work best in the ratio of 40:1 myo-inositol to d-chiro-inositol which is what is found naturally in the human body. They help in restoring hormonal and metabolic parameters which includes things like improving egg quality and ovulation, dyslipidemia, improving insulin sensitivity, leveling out androgens levels, increasing insulin sensitivity, and decreasing inflammation.

What’s really cool is that there is good research showing the effect of this 40:1 ratio in comparison to metformin. You may have heard of metformin before because it’s a common medication used to treat type 2 diabetes. It also works in women with PCOS to increase insulin sensitivity, improve ovulatory function and menstrual regularity. The drawback for some women is that is causes unpleasant gastrointestinal symptoms, while inositol is quite well tolerated although some women, although uncommon, do experience low blood sugar. There is still more research needed, but there are studies I’ve referenced at the bottom that have shown inositol to improve PCOS symptoms better than metformin. In a more recent study, women took either 1500mg of metformin OR myo-inositiol and d-chiro-inositol in a 40:1 ratio every day for 12 weeks. What did they find? Inositol supplementation showed significantly better improvement in ovulation and conception rates (46.7% and 11.2%) versus the 1500mg of metformin at 13.5% and 3%. Inositol also showed significant improved in progesterone levels and weight loss. **Weight loss unrelated to diet, rather inositol helps improve hormonal imbalances that cause the challenging metabolic dysregulation in women with PCOS.

The recommended dose of inositol (in that 40:1 ratio of myo-inositol to d-chiro-inositol) is 2000mg to 4000mg of myo and 50 to 100mg of d-chiro. You can also take inositol with metformin if you’re already taking metformin and your HCP suggests that and it works for you. You could purchase each supplement separately and take it in that ratio, or Ovasitol which is a supplement made in that 40:1 ratio for about $25/month.

Omega 3s

Omega 3s are essential fatty acids that the body cannot make on its own so we have to get them from food or supplements. Fish oil, either in supplement form or found in food, contains both EPA and DHA which are building blocks for cell membranes and hormones. They have been well researched and have been proven to help decrease inflammation, improve insulin resistance, and improve the lipid profile by increasing HDL (your “happy” cholesterol that you want to be high), lowering triglycerides and lowering LDL (your “lousy” cholesterol that you want to be low). Omega 3s have also been shown to improve mood and women with PCOS experience higher rates of anxiety and depression. If you’re eating omega 3 rich fish (such as salmon, tuna and sardines) 2-3 times a week along with other omega 3 rich foods you might be getting your needed dose. But most of us, including myself, don’t do that. So a supplement can be helpful.

Along with improving lipid profiles, there’s also research showing omega 3s shorten the length in between menstrual cycles so cycles become more regular in women with PCOS. Omega 3s have also been shown to reduce testosterone levels. Check with your health care provider first, but an optimal dose for women with PCOS is 2-3g of fish oil per day. Look for high quality brands (which have been purified) with a good amount of EPA and DHA per dose. Nordic Naturals is a good brand that’s not too expensive and Eukonic is another brand that’s high quality and a touch cheaper per daily dose. Food sources have better health benefits than supplements, so while including frequent sources of omega 3 fats in your diet is good and something to aim for, sometimes taking a supplement is necessary and can make life a bit easier.

Vitamin D

I’ve found in my nursing practice, especially when I was working in primary care, that the majority of people are deficient in Vitamin D. That’s just my observation, but something I noticed as I practiced. Particularly for women with PCOS, more often than not they are deficient in Vitamin D. Vitamin D (which is a hormone) plays many roles in the body, including that key word again, inflammation… in addition to bone, cardiovascular and immune health, muscle function, fertility and menstrual regularity, depression, cognitive function, metabolism, blood sugar regulation and insulin metabolism. For women with PCOS, Vitamin D has a significant impact on fertility, glucose and insulin metabolism, androgen levels and the underlying inflammation. It’s been shown to lower testosterone levels, improve egg quality and development, and reduce inflammatory markers – C-reactive protein (CRP) being one that is found to be higher in women with PCOS.

Your health care provider can easily check your Vitamin D levels with a quick blood test. When you see your lab results, you’ll notice that the lower range of “optimal” is 20-30 ng/mL but that’s actually often too low and often a level of at least 50 ng/mL is optimal. Since Vitamin D is a fat soluble vitamin, you don’t pee it out, so your levels can get too high. I’d recommend getting a blood test to assess your current levels before taking any supplementation and then getting your level checked every 3-6 months to ensure you’re in a good range. Also keep in mind that pregnancy and breastfeeding deplete Vitamin D levels, so even more reason to make sure your levels are adequate. Your health care provider should be checking Vitamin D levels at your annual physical exam. There’s no known “optimal dose” of vitamin D for women with PCOS, your health care provider can suggest a dose based on your current level. And they can prescribe a 50,000 IU dose that you take once a week for 8 weeks to get your levels up rather quickly. For women with PCOS, typically 2000 to 4000 IUs/day is a helpful “maintenance” dose to keep Vitamin D levels optimal if you are often low, but again check with your doctor and then get your levels checked regularly. You’ll want to make sure you’re taking Vitamin D3. Fortified foods, sunshine and fatty fish like salmon are good food sources as well.

There are other supplements that can help with PCOS, but these are a few that have been well researched with compelling benefits. In addition to lifestyle changes, supplements can be really helpful in managing PCOS and significantly improving symptoms. And sometimes, women need lifestyle changes and supplements, in addition to medications to help manage their PCOS and that’s okay too. Everyone is different and the best thing is to do what works best for you. My hope is that women feel empowered, knowledgable and advocates for themselves. Two other RDs who are really great resources you can check out for further info is the work of Julie Duffy Dillon and Angela Grassi. Angela lives with PCOS herself and has dedicated her entire career (20+ years) to the research and treatment of PCOS. Highly recommend both! Also Rachel has a great post on disordered eating and eating disorders in women with PCOS that I think is so very important to read. I hope this has been helpful! If you have more questions, leave them in the comments and perhaps I’ll do a Q&A style post answering them the best I can.

References

Vittorio Unfer, John E. Nestler, Zdravko A. Kamenov, Nikos Prapas, and Fabio Facchinetti, “Effects of Inositol(s) in Women with PCOS: A Systematic Review of Randomized Controlled Trials,” International Journal of Endocrinology, vol. 2016, Article ID 1849162, 12 pages, 2016. https://doi.org/10.1155/2016/1849162.

Benelli, E., Del Ghianda, S., Di Cosmo, C., & Tonacchera, M. (2016). A Combined Therapy with Myo-Inositol and D-Chiro-Inositol Improves Endocrine Parameters and Insulin Resistance in PCOS Young Overweight Women. International Journal of Endocrinology, 2016, 3204083. http://doi.org/10.1155/2016/3204083

Hamid, A. M., Madkour, W. A., & Borg, T. F. (2015). Inositol versus Metformin administration in polycystic ovary syndrome patients. Evidence Based Womenʼs Health Journal,5(3), 93-98. doi:10.1097/01.ebx.0000466599.33293.cf

Khani, B., Mardanian, F., & Fesharaki, S. J. (2017). Omega-3 supplementation effects on polycystic ovary syndrome symptoms and metabolic syndrome. Journal of Research in Medical Sciences : The Official Journal of Isfahan University of Medical Sciences, 22, 64. http://doi.org/10.4103/jrms.JRMS_644_16

Nadjarzadeh, A., Dehghani Firouzabadi, R., Vaziri, N., Daneshbodi, H., Lotfi, M. H., & Mozaffari-Khosravi, H. (2013). The effect of omega-3 supplementation on androgen profile and menstrual status in women with polycystic ovary syndrome: A randomized clinical trial. Iranian Journal of Reproductive Medicine, 11(8), 665–672.

Mehri Jamilian,Fatemeh Foroozanfard, Elham Rahman. Effect of Two Different Doses of Vitamin D Supplementation on Metabolic Profiles of Insulin-Resistant Patients with Polycystic Ovary Syndrome. Nutrients. 2017 Dec; 9(12): 1280.

Divyesh Thakker, Amit Raval, Isha Patel, and Rama Walia, “N-Acetylcysteine for Polycystic Ovary Syndrome: A Systematic Review and Meta-Analysis of Randomized Controlled Clinical Trials,” Obstetrics and Gynecology International, vol. 2015, Article ID 817849, 13 pages, 2015. https://doi.org/10.1155/2015/817849.