Main article: Treatment of Polycystic Ovary Syndrome Overview

Updated: 18-October-2024

Natural Treatment of Polycystic Ovary Syndrome

Doctors often recommend treating PCOS naturally first if they believe there is room for improvement. This strategy also helps later on if conventional treatment (i.e. medication) is still required.

Natural treatment options for women with PCOS include:

• Exercise
• Diet
• Losing weight
• Reduce stress
• Environmental
• Supplements

The actual treatment plan will depend greatly on any findings during initial examination and blood tests. Similarly, follow up blood tests and examination are also necessary to monitor (and adjust) the treatment plan.

Exercise

Exercise and being active is very important for women with PCOS. Early PCOS studies reported a link between physical inactivity, sedentary lifestyle and PCOS.^1,2,3

Subsequent lifestyle modification studies reported a significant decrease in PCOS symptom severity which could reduce the need for medication or dosage levels for some women.⁴ Hence lifestyle modification (i.e. diet and exercise) is usually the first treatment option doctors recommend to women with PCOS.⁵

However exercise is reported to be more effective than diet at improving insulin levels.⁶ Exercise also decreases oxidative stress and inflammation, which directly improves ovary function and hormone levels.^7,8

Among the various types of exercise, high-intensity interval training (HIIT) has the greatest impact on PCOS when compared to continuous aerobic exercise training (CAET), moderate-intensity continuous training (MICT) or resistance training.^9,10 In one study, Benham et al. reported that HIIT significantly improved lipid profile (LDL, HDL, cholesterol) more than CAET, even though the reduction in BMI and waist circumference was similar.¹¹ In a larger study, HIIT significantly improved sex hormone-binding globulin (SHBG), free androgen index (FAI), insulin sensitivity and menstrual cycles compared to MICT among overweight women with PCOS.¹²

Significantly, Lionett et al. reported that the effect of HIIT is somewhat impaired in women with PCOS, suggesting metabolic inflexibility and a need for medication during lifestyle modification to maximise the effect of HIIT.¹³

Lastly, research also suggests that supervised exercise is more effective than self-regulated exercise long term (> 3 months) if that is a viable option.¹⁴

Diet

A woman’s diet can positively influence the symptoms and severity of PCOS. On their own, the Mediterranean plus low carb diet or the low fat diet both reduce the severity of PCOS.^15,16

However when combined, these diets resemble a low inflammatory diet which has been shown to very effective in women with PCOS due to the inflammatory nature of the condition.^17,18

For women with PCOS, this means a diet high in fibre, polyunsaturated fats, fruits and vegetables, whilst low in cholesterol, saturated and trans fats, as per the dietary inflammatory index system.¹⁹

Experts also recommend minimal snacking or skipping of meals and limiting alcohol intake to help maintain regular cycles.²⁰ Snacking particularly after dinner is most likely to overload the body’s glucose response. Similarly, eating a large dinner instead of a large breakfast worsens insulin resistance and hyperandrogenism in women with PCOS.²¹ Predictably, Papakonstantinou et al. reported that having 6 smaller meals a day instead of the usual 3 significantly improves insulin sensitivity.²²

Losing weight

Overweight women can significantly reduce the severity and symptoms of PCOS by losing weight. Kiddy et al. reported that losing just 5% of body weight significantly increased SHBG, decreased free testosterone and insulin levels among women with PCOS, which subsequently improved menstrual cycles and hirsutism.²³

Weight loss is usually achieved by calorie restriction and or exercise although women with severe insulin resistance may also need medication (i.e. insulin sensitizer) to help the body respond more efficiently.

Women with PCOS can also lose weight by simply intermittent fasting. In 2 similar studies, intermittent fasting (between 4-6pm to 8am) caused significant weight loss (1.3-2.9kg over 5-8 weeks). Insulin, hormone (TT, SHBG) levels, and inflammation (hsCRP) also decreased, while liver health (ALT) and menstrual cycles significantly improved.^24,25

Talebi et al. demonstrated that time-restricted eating is just as effective as calorie-restricted diets and a viable alternative for women who don’t want to count calories. Although, women should monitor thyroid health as Jiskoot et al. reported a noticeable increase in TSH levels during a separate trial. Researchers suggest this may be a result of the different fasting period (9pm to 1pm) but requires further investigation.²⁶

Regardless of which weight loss method women choose, regular support from other health professionals (e.g. dietician, trainer, psychologist) is recommended to increase the likelihood of weight loss.^27,28

Reduce Stress

Studies suggest women with PCOS are somewhat more sensitive to stress, which is a well known cause of amenorrhea and polycystic ovaries (PCOM), even among healthy women.²⁹

In healthy women, acute stress significantly increases DHEA and DHEA-S, which is elevated in approximately 1 in 3 women with PCOS.^30,31,32,33

Cortisol is a well-known stress-biomarker however experts report elevated prolactin levels in women with PCOS can also indicate chronic stress when cortisol levels do not.³⁴ This is because the role of cortisol is more complex than first thought especially in women with PCOS.³⁵

Instead women should use the validated Perceived Stress Scale (PSS-10) questionnaire to assess their stress levels and seek help if required.³⁶

Environmental

Women with PCOS are more sensitive to the environment around them, namely certain chemicals or compounds.

Bisphenols are one of the most abundant endocrine disrupting chemicals in the world. Majewska et al. reported that the greater the exposure to bisphenols the more likely women were to be diagnosed with PCOS.³⁷ Studies indicate BPA amplifies the hormone dysfunction caused by PCOS.³⁸ Even Bisphenol S (BPS), a common substitute for BPA, was found elevated in women with PCOS.³⁹ Although less effective than BPA, BPS is also an androgen receptor blocker. In vitro and in vivo studies show BPS mechanism of action is similar to that of BPA, and can affect ovarian follicles, androgen production and oocyte quality.⁴⁰

Other endocrine disrupting chemicals such as polychlorinated biphenyls (PCBs) and polycystic aromatase hydrocarbons (PAHs), found in cigarette smoke, is reportedly higher among women with PCOS.^41,42 Studies show that both first and second hand smoking worsens the hormonal and metabolic profile of women with PCOS, in a dose dependent manner, and can also disrupt the follicular microenvironment directly via endoplasmic reticulum stress.^43,44,45

Lastly, exposure to perfluoroalkyl substances (PFAS) commonly used to make water / stain resistant fabrics (or carpets), non-stick cookware, line paper or paperboard food packaging, and in some treated plastics is also linked to an increased risk of PCOS.^46,47

Supplements

The following supplements are beneficial for women with PCOS:

• Acetyl-L-Carnitine
• Alpha-lipoic Acid
• Coenzyme Q10
• Melatonin plus Magnesium
• Selenium
• Ellagic acid
• Synbiotics
• Spinach
• One-Carbon Metabolism
• Vitamin B1
• Vitamin K2
• Vitamin D
• Vitamin D plus Calcium
• Inositol
• Berberine
• Omega-3
• Quercetin
• Tea
• Curcumin nanomicelle

These supplements work by targeting either inflammation, insulin resistance, vitamin or mineral deficiencies.

Having regular blood tests (every 3-6 months) will also help you doctor evaluate the treatment plan and make any changes if needed.

Acetyl-L-Carnitine

Acetyl-L-Carnitine (ALC) is an essential amino acid involved in energy production, oxidative stress and glucose metabolism.

Fenkci et al. reported that L-carnitine levels are significantly lower in non-obese women with PCOS and insulin resistance.⁴⁸

Subsequent studies report taking 3g a day of L-Carnitine for 3 months significantly decreased insulin levels and HOMA-IR. This helped overweight women with PCOS to lose weight and improve their menstrual cycles more than medication alone (metformin plus pioglitazone).^49,50

Alpha-Lipoic Acid

Alpha-lipoic Acid (ALA) is a broad-spectrum agent with antioxidant, anti-inflammatory and insulin sensitizing effects.⁵¹

Alpha-lipoic acid supplementation significantly improves insulin response, total antioxidant capacity, menstrual cycles and liver function among women with PCOS and insulin resistance. However no change in hormone levels was reported after 3 to 6 months confirming ALA is strictly a complementary medicine.^52,53,54

Instead studies routinely combine alpha-lipoic acid with myo-inositol to improve the metabolic parameters of women (and adolescents) with PCOS and a family history of diabetes.^55,56,57 Genazzani et al. reported that the addition of ALA to myo-inositol improved the hormone and metabolic profile, including insulin response (OGTT), of all women with PCOS independent of familial diabetes.⁵⁸

Coenzyme Q10

Coenzyme Q10 (CoQ10) is an essential molecule with bioenergetic and antioxidant properties. In a small placebo-controlled trial, 12-week administration of CoQ10 (100 mg/day) to women with PCOS improved various markers related to hyperandrogenism (total testosterone, SHBG, DHEAS), inflammation (hs-CRP) and oxidative stress (MDA, TAC).⁵⁹ This leads to a small improvement in metabolic parameters (i.e. insulin, HOMA-IR).⁶⁰

Melatonin plus Magnesium

Melatonin and magnesium both have antioxidant and anti-inflammatory effects on the body.⁶¹

Melatonin regulates steroidogenesis, folliculogenesis and oocyte maturation within the ovary.^62,63 Consequently melatonin supplementation significantly reduces total testosterone, AMH, inflammation (hs-CRP, IL-1,TNF-α) and oxidative stress (MDA, TAC, glutathione) in women with PCOS causing a noticeable improvement in menstrual cycles.^64,65

Magnesium on the other hand plays a role in the bodies antioxidant defenses as an essential cofactor. Women with PCOS are less likely to eat magnesium rich foods with low levels of magnesium associated with worsening PCOS status, particularly insulin resistance and testosterone levels.^66,67 However studies evaluating the impact of magnesium supplementation in women with PCOS have been inconsistent to date.^68,69

Interestingly, a randomized placebo controlled trial showed that the combination of magnesium oxide (250mg) and melatonin (6mg) daily over 8 weeks had a greater effect on insulin, hirsutism, total testosterone, total antioxidant capacity, inflammation and menstrual cycles in women with PCOS than melatonin or magnesium alone.^70,71

Selenium

Selenium is an essential nutrient, with anti-inflammatory and antioxidant properties, that is found decreased in some women with PCOS.^72,73,74

In a randomized double-blind placebo-controlled trial, involving women with PCOS, 200μg of selenium + Metformin (1500mg) daily for 8 weeks significantly decreased inflammation (hs-CRP, MDA), hirsutism (mF-G) and DHEA levels compared to women taking the placebo + Metformin.⁷⁵

A more recent study also reported that infertile women with PCOS, who only took 200μg of selenium daily for 8 weeks, had significantly improved glycemic control (insulin, HOMA-IR).⁷⁶

However further studies, more comprehensive and larger in size, are still required to better understand the effects of selenium deficiency and supplementation in women with PCOS.

Ellagic Acid

Ellagic acid is a natural polyphenol found in fruits and vegetables with strong antioxidant properties.

In the only PCOS study to date, non-obese women (BMI<30) with PCOS and insulin resistance, took 200mg/day of ellagic acid for a period of 8 weeks.⁷⁷ At the end of treatment, follow-up blood tests showed ellagic acid significantly:

• Reduced levels of fasting blood sugar (94.3 vs. 106.2 mg/dL)
• Decreased insulin levels (9.6 vs. 14.0 µU/ml)
• Reduced HOMA-IR (2.2 vs. 3.7)
• Improved oxidative stress (TAC, MDA)
• Decreased inflammation (TNF-α, CRP)
• Improved lipid profile

These improvements caused a significant decrease in total testosterone (0.38 vs. 0.59 ng/ml), prolactin (12.3 vs. 19.0) and AMH levels (7.2 vs. 11.9 ng/ml), but only a small decrease in LH levels (9.7 vs. 10.8 ng/ml).

Ellagic acid is naturally found in numerous fruits and vegetables, including grapes, strawberries, red raspberries and pomegranates (100mg/L), although concentrated capsule supplementation may be required to achieve 200mg/day intake and reported outcomes.^78,79

Synbiotics

Synbiotics is the synergistic combination of prebiotics and probiotics to support gut health.

There are several small studies supporting the use of prebiotics and probiotics by obese women with PCOS. Consistent improvements are seen in both insulin resistance and sensitivity, weight and BMI. Although the duration of trials was either 8 or 12 weeks, with different combination of strains and final capsule concentrations, similar results suggest that synbiotic supplementation may reduce adiposity in overweight women with PCOS, although further studies are required to understand exactly how this occurs.^80,81,82

Spinach

Green leaf membranes (thylakoids) found in spinach is known to increase fullness and reduce cravings among men and women.⁸³

Similarly, PCOS studies also report that thylakoid‐rich spinach extract suppresses appetite and hunger. 5 grams/day of thylakoid‐rich spinach extract combined with a low calorie diet for 12 weeks caused a significant decrease in insulin resistance, total testosterone and fat mass compared to the placebo controlled group.^84,85

One-Carbon Metabolism

One-carbon metabolism is a complex network that encompasses both the folate and methionine cycles, and allows cells to generate one-carbon units.

Homocysteine (Hcy) is a commonly used biomarker to monitor one-carbon metabolism. Studies show homocysteine levels are elevated in women with PCOS, especially vegetarians.^86,87,88

Elevated homocysteine levels (hyperhomocysteinemia) is normally treated with dietary changes, folate and or vitamin B12 supplementation.⁸⁹

In cases where homocysteine levels have not decreased to normal, research suggests a multivitamin that provides broad support of the carbon cycle can bypass genetic blockades and avoid needing high doses of folate.⁹⁰ In this study, women with PCOS took a daily multivitamin containing:

• 200mg betaine
• 200mg L-cystine
• 10mg chelated zinc
• 16mg niacin (Vitamin B3)
• 1.4mg pyridoxine (Vitamin B6)
• 1.4mg riboflavin (Vitamin B2)
• 400 μg 5-methyl-tetrahydrofolate (Folate)
• 2.5 μg methylcobalamin (Vitamin B12)

After 3 months supplementation, homocysteine levels decreased by one third (8.1 vs. 11.9 μM/L) and treatment of hyperhomocysteinemia was successful in 7/8 women.

Vitamin B1

Vitamin B1 (thiamine or thiamin) is an essential water-soluble vitamin associated with cellular energy metabolism and oocyte maturation.⁹¹

Women with PCOS often have low levels of vitamin B1 due to diet, reduced intestinal absorption, and or increased loss through their urine (due to medication).⁹²

A small study recently reported that 4 weeks of vitamin B1 supplementation (300 mg/day) significantly improved the general health of women with PCOS (anxiety, depression, insomnia).⁹³

Vitamin K2

Vitamin K2 is a fat-soluble vitamin that is mostly obtained from meat, cheese, and eggs. Studies suggest vitamin K affects glucose metabolism by improving insulin sensitivity and β‐cell function.⁹⁴

In a randomized placebo-controlled trial, 90µg of Vitamin K2, daily for 8 weeks, significantly improved insulin resistance, SHBG and FAI, which helped women with PCOS naturally lose fat mass. Depression status also improved however more studies are required to verify these results.^95,96

Vitamin D

Insufficient vitamin D levels is common in overweight women (adult and adolescent).⁹⁷ Although women should also check their magnesium levels, as vitamin D is strongly regulated by magnesium.⁹⁸

Current studies estimate women require 70–80 IU/kg of vitamin D to produce a normal concentration of 30–40 ng/ml.⁹⁹

In 2018 a placebo controlled trial featuring 60 women with PCOS, BMI (31±5) and insufficient vitamin D levels, reported that vitamin D supplementation (50,000 IU per week) together with a low-calorie diet significantly improved menstrual cycles and possibly testosterone levels (0.7 to 0.5 ng/ml, p=0.18.).¹⁰⁰

A later trial also reported that 12 weeks of vitamin D supplementation (50,000 IU per week) increased SHBG and decreased FAI, hirsutism and polycystic ovaries, among overweight women with PCOS, which restored regular menstrual cycles.¹⁰¹

In another trial, vitamin D supplementation of 20,000 IU per week for 6 months also increased FSH levels significantly and improved the LH/FSH ratio among overweight women with PCOS however no change in AMH levels (i.e. polycystic ovaries) was noted.¹⁰²

In the most recent study, Ağar et al. reported that both lean and obese women with PCOS, deficient in vitamin D (< 20 ng/mL), achieved a significant reduction in inflammation and insulin resistance with just 2000 IU/day of vitamin D supplementation.¹⁰³

Vitamin D plus Calcium

Calcium levels (or homeostasis) in the body is strictly regulated by the endocrine system including parathyroid hormones, vitamin D and calcitonin. Therefore in some women with normal serum calcium concentration levels, abnormally elevated parathyroid hormone levels is responsible for the dysregulation of calcium homeostasis.

An early study of calcium and vitamin D combined supplementation, in 13 overweight or obese women with PCOS, restored normal menstrual cycles in all 13 women within 6 months (and seven women within 2 months).¹⁰⁴

Interestingly, a larger study reported that serum levels of gonadotropins (LH, FSH) or insulin-like growth factors (IGF-1, IGFBP-1) does not change significantly with combined supplementation.¹⁰⁵ This indicates a different pathway by which vitamin D and calcium helps regulate menstrual cycles.

In fact, 1 in 2 non-obese vitamin D deficient women with PCOS see a return of regular menstrual cycles after 3 months of vitamin D and calcium supplementation. As expected LH, FSH, E2 and DHEAS hormone levels did not change, but total testosterone and FAI decreased, and SHBG increased significantly.¹⁰⁶

Inositol

Inositols are insulin sensitizers which participate in different insulin dependent processes as messengers. Myo-inositol is involved in cellular glucose uptake while D-chiro-inositol is part of glycyogen synthesis.

In the ovary itself, myo-inositol is involved in FSH signalling and D-chiro-inositol in the insulin-mediated production of androgen. The 2 inositols are present in tissues and organs at specific ratios. However in women with PCOS, this ratio is unbalanced and D-chiro-inositol elevated.¹⁰⁷ As a result, D-chiro-inositol only supplementation tends to worsen hyperandrogenism.^108,109

Myo-inositol on the other hand produces similar outcomes to metformin (i.e. decreased insulin resistance, total testosterone and free testosterone). However, unlike metformin, the risk of adverse (gastrointestinal) events is significantly less with myo-inositol. In fact, no difference was found between myo-inositol and metformin treatment in fasting insulin, HOMA-IR, testosterone, SHBG levels and BMI suggesting myo-Inositol maybe better for women with PCOS.^110,111,112

Unfortunately not all comparative studies between myo-inositol and metformin report similar results. In reality, some women with PCOS (e.g. non-hyperandrogenic PCOS) just do not respond favourably to inositol, also known as inositol resistant.¹¹³

Inositol resistance can be overcome sometimes by combining myo-inositol with alpha-lipoic acid (ALA) or alpha-lactalbumin (alpha-LA) to improve treatment outcomes independent of ethnicity, metabolic profile or familial diabetes (but not type D PCOS).^{114,115,116,117,118,119} Alpha-lactalbumin may also have ‘prebiotic effects’ limiting PCOS induced intestinal and vaginal dysbiosis.¹²⁰

Please note, consuming coffee and powered myo-inositol together is reported to significantly impair absorption.¹²¹ Experts recommend switching to the soft gel capsule form of myo-inositol or consuming coffee at least 1 hour before/after myo-inositol.¹²²

Berberine

Berberine is an alkaloid found in plants and commonly used in chinese herbal medicine. Various studies have suggested berberine as a natural alternative to metformin with less side effects, and comparable to myo-inositol.^123,124

Berberine main target is the AMP-activated protein kinase involved in fatty acid oxidation, glucose generation, and insulin resistance, although it also improves antioxidant and inflammatory levels.

In one study, berberine significantly improved markers of hyperandrogenism (testosterone, androstenedione, FAI, SHBG), anthropometry (waist circumference), insulin resistance and lipids (LDL, triglycerides) with almost half of the oligomenorrhea PCOS study group (22/50) having regular ovulatory cycles after 6 months of treatment.¹²⁵

In the last few years, new formulations of berberine (e.g. Phytosome, Liposomal) have been developed to improve the bioavailability of berberine. Unfortunately, none of these formulations have been directly compared to the previous formulation of berberine in women with PCOS.^{126,127,128,129}

Please note the long-term safety of berberine remains unknown in humans although animal studies suggest possible liver damage.¹³⁰

Omega-3

Omega-3 fatty acids are essential healthy fats that can not be produced by the body. Researchers believe PCOS causes dysfunction in adipokine production and the omega-6/omega-3 ratio.¹³¹

Nadjarzadeh et al. reported that omega-3 supplementation significantly reduces testosterone levels, and increases regular menstruation, after 8 weeks in women with PCOS. However there was no change in SHBG or FAI.¹³²

Subsequent studies showed that omega-3 supplementation significantly improves total cholesterol, triglycerides and insulin sensitivity among PCOS women.^133,134

Overall, this suggests that omega-3 is only a complementary medicine for PCOS and should be combined with other medication or supplements.

Quercetin

Quercetin is a natural flavonoid with anti-carcinogenic, anti-diabetic, anti-inflammatory, antioxidant, and anti-hyperlipidemic effects which has been proposed as a natural alternative to metformin.¹³⁵

In 2017 a randomized placebo-controlled double-blind trial reported that 1g of quercetin daily for 12 weeks had mild benefits in overweight women with PCOS, decreasing mostly insulin resistance (HOMA-IR 1.84 vs. 2.21), which slightly improved testosterone (0.71 vs. 0.77 ng/dl) and LH (8.4 vs 8.7 IU/l) levels.^136,137

A later study, among non-overweight women with PCOS, also reported a reduction in LH levels and inflammation (IL6, TNF-α) after taking 500mg of quercetin daily for 40 days.¹³⁸

Tea

Tea is a popular beverage globally with many medicinal properties. Several studies to date have investigated the benefits of both green tea and spearmint tea among women with PCOS.

Green tea consumption reduces insulin levels which helps women with PCOS lose weight and slowly improve their hormone levels after 3 or more months.^139,140

On the other hand spearmint tea directly reduces hyperandrogenism and hirsutism in women with PCOS, but can worsen the LH:FSH ratio.^141,142

However tea consumption is not without any side effects. Excess amounts of green tea is known to cause gastrointestinal side effects and sometimes liver damage in extreme cases.¹⁴³ Consuming tea too close to meal time can also interfere with the absorption of micronutrients (e.g. iron).¹⁴⁴

Consequently, experts recommend a maximum of 3 cups of tea per day (or equivalent tea extract) at least 1 hour or more before each meal to maximize the appetite suppressant effects, and minimize any negative effects.¹⁴⁵

Curcumin Nanomicelle

Curcumin is a substance found in the spice turmeric with anti-inflammatory and hypoglycemic (insulin secretion) properties.

Curcumin alone is of mild benefit to women with PCOS improving menstrual cycles somewhat after taking 1000mg/day for 3 months.^146,147

On the other hand, curcumin plus metformin appear to complement each other in a synergistic manner. Sohrevardi et al. reported that just 80mg/day of curcumin nanomicelle plus metformin, for 3 months significantly reduced fasting insulin, total testosterone and total cholesterol levels more than metformin alone.¹⁴⁸

A Tip From Fertility Science

PCOS is a complex condition which can disturb numerous systems in the body but affects every woman differently.

It’s important women always undergo a thorough diagnosis of their condition to identify any comorbidities and or deficiencies alongside PCOS before commencing treatment.

A holistic approach to diagnosis and treatment is key to managing your condition effectively. This often means a combination of natural and conventional treatment options in reality.

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