What Causes PCOS?

ovarian cyst ovarian cysts cysts on the ovaries in pcos

PCOS is caused by High Androgens – Except When it’s Not

By Dr. Pamela Frank, BSc(Hons), ND

PCOS or polycystic ovarian syndrome is a collection of symptoms that affects 8-10% of women of reproductive age.  A syndrome is a collection of symptoms, some or all of which may be present.  It can present at different times of a woman’s life, meaning things may have all been normal at some point, but later periods may become irregular and hormone imbalance symptoms may appear.

What Causes PCOS?

There is a common erroneous assumption that if a woman presents with symptoms related to PCOS (acne, oily skin/hair, irregular periods, excessive facial or body hair, infertility) that she must have high levels of androgens.  This assumption wrongly pigeon holes 40% of women with PCOS symptoms into the category of insulin resistant and high androgen levels.  60% of women with PCOS symptoms do have insulin resistance and elevated levels of DHEAs and/or testosterone.  However, the remaining 40% do not.  In these women PCOS symptoms have a different root cause that needs to be investigated.

Two Examples of Alternative Causes of PCOS Symptoms

  1. Hyperprolactinemia (high blood prolactin levels) – Prolactin is a hormone produced by the pituitary to stimulate production of breast milk for breastfeeding. However, prolactin levels can also be elevated due to stress and/or due to a benign pituitary tumor called a prolactinoma. Prolactin interferes with normal ovulation and PCOS-like symptoms arise due to the changes in the normal production of the female hormones estradiol and progesterone.
  1. Hypothyroidism – An underactive thyroid slows the function and metabolism of all of the body’s cells, including the cells in the ovaries that should be maturing egg follicles into eggs. Irregular ovulation occurs, leading to lower levels of estradiol and progesterone.

How to Know What is Causing your PCOS

The only way to accurately determine whether you have PCOS and why is to perform a complete battery of tests (as appropriate to you and determined by your doctor), that may include:

Fasting blood sugar and insulin


Testosterone – total and free

LH, FSH, and Estradiol (if cycles are present, preferably day 3 of the menstrual cycle)

Progesterone (if cycles are present, preferably 7 days post expected ovulation)

TSH (I prefer a full thyroid screen including fT3, fT4, anti-TPO and anti-thyroglobulin antibodies)

Prolactin (I prefer to see more than one, as the level is variable day to day)


Lipid Profile

Pelvic and Transvaginal ultrasound


Iptisam Ipek Muderris,a Abdullah Boztosun,b Gokalp Oner,a and Fahri Bayramc Effect of thyroid hormone replacement therapy on ovarian volume and androgen hormones in patients with untreated primary hypothyroidism. Ann Saudi Med. 2011 Mar-Apr; 31(2): 145–151.

Islam S, Pathan F, Ahmed T. Clinical and Biochemical Characteristics of Polycystic Ovarian Syndrome among Women in Bangladesh. Mymensingh Med J. 2015 Apr;24(2):310-8.

PCOS Infertility

pcos and infertility

PCOS Infertility: Alternatives to IVF

PCOS has not been proven to necessarily cause infertility, yet many women once diagnosed with PCOS despair that they will never have children. This grief and despair is unwarranted and unnecessarily stressful for these women. Despite what they are lead to believe, not only can women with PCOS conceive and have healthy children, they can do so, in many cases, naturally (without the use of drugs and IVF).

How does PCOS cause infertility?

By definition, PCOS entails a lack of ovulation, at least on some cycles. Egg follicles begin to develop but don’t mature properly to get released and become cysts on the ovaries. If an egg doesn’t get released, obviously pregnancy will be impossible to achieve. PCOS disrupts ovulation due to altered hormone balance. 60% of women with PCOS will have elevated androgens (testosterone and/or DHEAs). Androgens interfere with ovulation by suppressing egg development and estrogen production. In other women with PCOS, elevated levels of prolactin can equally suppress egg development and ovulation. In still another subset of PCOS, ovulation isn’t happening because there isn’t enough estrogen being produced to get eggs to mature. Yet other women have endocrine system issues with the adrenal glands and/or thyroid. Addressing these organs and enhancing their function helps reverse PCOS. In any of the above scenarios, if ovulation doesn’t occur regularly, then fertility is decreased. If it doesn’t happen at all, then pregnancy is impossible until you correct the reason why ovulation isn’t occuring. Each of the above deterrents to ovulation can be addressed and resolved.

How do I know which kind of PCOS I have?

Extensive, thorough lab testing is vital to determine which scenario is the cause of your PCOS. It is not one size, fits all.  Everyone does not have PCOS for the same reason or has the same hormone imbalance. Almost 100% of the women that I see with PCOS have NOT had adequate testing done to truly identify what is causing their polycystic ovarian syndrome. Thin women have been told they don’t have PCOS because they don’t look like it. This is nonsense. Up to 40% of women with PCOS ARE thin. Having acne or hair loss does NOT mean that your PCOS is caused by testosterone. Assumptions are made incorrectly.

The following tests should be done (as appropriate to the person): HbA1c, fasting insulin, fasting glucose, total and free testosterone, DHEAs, DHT, prolactin, androstenedione, thyroid testing (TSH, free T3, free T4, anti-TPO and anti-thyroglobulin), if cycles are present, day 3 LH, FSH and estradiol (otherwise do a random estradiol), and day 21 progesterone as well as a pelvic and transvaginal ultrasound.

What are the alternatives to IVF in PCOS?

  1. I’ll break down alternative treatment into the different PCOS types:
    High androgen type – these women have had blood tests that showed high levels of androstenedione, and/or DHEAs, and/or testosterone and/or DHT. This is the “Classic” PCOS and is usually related to elevated blood sugar and insulin. Insulin drives the excess production of androgens from either the ovaries or the adrenal glands. So the treatment is low glycemic index, low glycemic load diet, exercise, stress reduction and herbs/vitamins/minerals for blood sugar and insulin like inositol, chromium, vanadium, zinc, benfotiamine, berberine and cinnamon.
  2. High prolactin – In some instances, stress elevates prolactin, so the solution to high prolactin in these women is to reduce stress and/or add some additional stress reduction techniques like exercise, yoga, meditation and CBT. Other women will have a benign pituitary tumor known as a prolactinoma. In this case, there is a drug to reduce prolactin (bromocriptine or cabergoline) or in natural medicine, we use an herb called Vitex and vitamin B6 to lower prolactin.
  3. Low estrogen – Low output of estrogen can occur secondary to high androgens, in which case, the solution is to resolve the high androgens. In others, low estrogen can occur because of an underactive thyroid or underactive adrenal glands. In that case, the solution is to unearth why the gland isn’t working and rectify the situation. In the case of the thyroid, your thyroid may not be working well because a) you have an autoimmune thyroid disease known as Hashimoto’s, b) the thyroid is lacking nutrients to function normally (iodine, zinc, selenium, copper, tyrosine) or c) the thyroid isn’t working well because some other part of the endocrine system isn’t working well. The adrenal glands support normal ovarian function by supplying DHEAs and testosterone to the ovaries to make into estrogen. So, low estrogen output can be due to a lack of building blocks coming from the adrenal glands. The adrenals are your stress glands, so stress reduction is vital to enabling them to function normally. They require vitamin C, B5, B6, magnesium and zinc to function well, so restoring adrenal function requires replenishing these nutrients.

Do the IVF alternatives work?

Yes, because they are addressing the root cause of the problem. I have seen it help hundreds of women conceive naturally and go on to have healthy pregnancies and healthy babies. These measures address the individual and the specific hormone imbalance going on in this particular woman with PCOS.

Why doesn’t the fertility clinic do this?

Your fertility clinic is following set guidelines to induce a pregnancy through drugs and ART. They do not specialize in investigating and addressing the root cause of polycystic ovarian syndrome or treating you as a unique individual.

Book an appointment now to discuss PCOS infertility with Dr. Pamela Frank, BSc(Hons), ND