Nourish to Flourish: Nutrition and Lifestyle Strategies for Managing PCOS

Guest post written by Chiara Toscano, recent Dietetics Graduate from the University of Ottawa

What if there was a hormonal condition that deeply affected your quality of life, physical health, and mental health? And what if this condition was a leading cause of infertility, yet took an average of 4.3 years and multiple primary care providers to diagnose? This is the reality for people living with Polycystic Ovarian Syndrome, or PCOS. This hormonal syndrome affects between 8 and 13% of adult women, or about 1.4 million Canadians. The cause of PCOS is unknown, but scientists believe that a combination of genetics and environmental factors contribute to its development.

As with so many conditions, there is a ton of information on the internet about miracle pills, supplements, diets, exercise routines, etc. that can drastically improve PCOS symptoms. But it can be hard to differentiate between reliable information and what may be an attempt to sell you something that ultimately does very little to help relieve your symptoms or improve your quality of life. In this post, we’ll explore what the science has to say about managing PCOS symptoms through nutrition and lifestyle. 

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A word on the use of gender-binary language

Many of the studies cited in this post refer to those with a uterus as ‘women’ or ‘females’. We recognize that not all those born with a uterus identify as women and that not all women have a uterus, for a variety of reasons. Those assigned females at birth with PCOS may still experience symptoms related to their condition and could benefit from the information presented in this post. We also recognize that those taking gender-affirming hormonal therapies have differing and complex experiences when it comes to PCOS, which is under-studied and beyond the scope of this post.

What is Polycystic Ovarian Syndrome? 

PCOS is a hormonal syndrome that causes a lack of ovulation, or irregular ovulation. It may also cause people to display signs of elevated male sex hormones or ‘androgens’, like testosterone. A classic sign of PCOS is the presence of multiple cysts on the ovaries - although this is not the case for all people with PCOS. In some, it can also cause insulin resistance and weight gain.

To be formally diagnosed with PCOS, you have to fulfill 2 of the 3 following criteria: 

1. Irregular menstrual cycles (related to irregular ovulation) 
2. Visible signs or elevated lab values of male sex hormones (androgens), like: 
1. Increased body hair on the face, chin, and abdomen
2. Acne, oily skin
3. Thinning hair / male pattern hair loss
3. More than 10 follicles (cysts) per ovary

Not everyone with PCOS will have exactly the same set of symptoms. In fact, scientists have identified different ‘phenotypes’ or subtypes of PCOS. For example, one person with PCOS may have elevated male sex hormones AND irregular periods AND multiple cysts on their ovaries. Another person might experience irregular periods AND cysts on their ovaries, but their male sex hormones are in the normal range. While both people have PCOS and will likely experience symptoms, the approach for managing the condition and the symptoms may be different. 

What are some other symptoms that people with PCOS may experience? Some classic ones include irregular periods, hirsutism or excess body hair, a male growth pattern of body hair (think upper lip, chin, back, stomach, around the nipples, etc.), acne, male pattern baldness, fatigue, low energy, mood swings, depression, anxiety, fertility problems, and acanthosis nigricans or areas of thickened, darkened skin. Some people may also experience an inability to lose weight despite intense exercise or diet. 

Hormones involved in PCOS

Now that we’ve discussed what PCOS is, let’s explore what hormones specifically are involved in this syndrome. PCOS typically causes elevated estrogen levels, elevated male sex hormone or ‘androgen’ levels (specifically, testosterone). In some cases, PCOS can also cause elevated insulin levels, the hormone responsible for helping your body use carbs as energy. People with PCOS also tend to have higher levels of luteinizing hormone (LH), the hormone responsible for triggering ovulation in women. In recent years, researchers have also noted that Anti-Müllerian Hormone (AMH) levels are higher in people with PCOS. This hormone is typically checked to evaluate fertility but is increasingly used for diagnosing certain uterine conditions.

Can you manage PCOS symptoms through food and lifestyle?

PCOS is a complex condition, and with multiple subtypes, one person’s experience of this syndrome may be wildly different than another’s. If you have PCOS or know someone who does, you are probably aware of how much information is out there on pills, supplements, diets, exercise routines, lifestyle changes, etc. that may help with PCOS symptoms. But how much of that information is backed up by science? And how much can nutrition and lifestyle really help with managing your PCOS symptoms? Let’s explore what the science has to say and share some simple ways to manage common PCOS symptoms through nutrition and lifestyle.

Irregular periods

An irregular menstrual cycle is a classic symptom of PCOS. Specifically, longer cycles or the absence of a period altogether, are common. Regulating your cycle can be helpful if you have fertility-related goals, or simply want to help manage your PCOS symptoms in general. In terms of nutrition, a few supplements and vitamins have been found to help promote more regular periods in people with PCOS. Inositol, sometimes referred to as ‘vitamin B8’, is not a vitamin at all but a type of sugar that is involved in how your body processes carbs. It also affects certain hormones (specifically testosterone) that contribute to PCOS symptoms. Studies have shown that myo-inositol, a specific type of inositol, can help increase menstrual cycle regularity. An important note is that this effect was found with long-term supplementation (greater than 6 months of daily supplementation). If you are looking to add some more inositol to your day through the foods you eat, some great sources include beans, nuts, fresh fruits, and whole grains. More studies are needed to determine exactly how much inositol people with PCOS should take, but typically studies used anywhere between 1 - 4 grams per day when studying its effects.  As always, it is important to check with a trusted healthcare professional before starting any supplement. 

Vitamin D plays an essential role in fertility and hormonal health. Studies have shown that vitamin D supplementation in women with PCOS has multiple benefits. It can decrease androgen levels and overall has a positive effect on the menstrual cycle. Having normal levels of vitamin D also increases your probability of ovulating when you have PCOS, when compared to people with low vitamin D levels.

TLDR; long-term, daily inositol supplementation may help improve your menstrual cycle regularity if you have PCOS. Vitamin D supplementation, if you have low vitamin D levels, can also help regulate your cycle.

Hormone imbalances

Elevated levels of certain hormones like testosterone, estrogen, insulin, LH and AMH are a key feature of PCOS. Medical interventions and medication are essential tools in managing these hormonal imbalances, but nutrition may help as well. Studies have shown that certain forms of inositol, specifically Myo-inositol and D-chiro-inositol, may help regulate Follicle-Stimulating Hormone (FSH) and testosterone production, which contribute to symptoms of excess androgens (acne, excess hair growth, male pattern balding, etc.). 

Women with PCOS tend to have higher levels of melatonin in their blood, however, they tend to lose greater amounts through their urine and have lower levels in their ovaries. Studies also show that people with PCOS tend to have worse sleep quality, for a variety of reasons. Unfortunately, poor sleep quality in turn worsens PCOS symptoms, creating a vicious cycle. So what can be done from a nutrition perspective? Melatonin supplements may help. Melatonin plays a role in regulating ovulation, and may also help decrease testosterone production in people with PCOS. It also has powerful antioxidant properties. This can be especially helpful in PCOS as oxidative stress and inflammation can exacerbate symptoms and hormonal imbalances (for example, leading to a lack of ovulation or irregular cycles). Studies have looked at long-term supplementation (greater than 6 months) and found that it may help improve levels of androgens, improve menstrual cycle regularity and even help with inflammation. 

TLDR; inositol supplementation may help with certain hormonal imbalances related to PCOS. Melatonin supplementation improves sleep quality in people with PCOS and shows promising effects on hormone imbalances as well.  

Fertility 

PCOS is a leading cause of infertility worldwide. For those with PCOS wishing to conceive, this can be an incredibly disheartening reality to accept. Thankfully, modern medicine provides a variety of treatment options to support fertility. If you are looking to support your fertility through nutrition, there are a few key nutrients that may help. N-acetyl cysteine (NAC) is the supplemental form of cysteine, a building-block of proteins in your body. It is also a powerful antioxidant. Food sources include any protein-rich foods, like meats, fish, beans, legumes, eggs, nuts and seeds, and certain cheeses. Some studies done on people with PCOS have shown that it may increase the odds of pregnancy and live birth, although these studies are small, and showed that NAC did not help as much as Metformin, a medication commonly prescribed to those with PCOS. It’s important to know that NAC supplements may interact with certain medications, so it’s also best to check with your doctor before trying.

Vitamin D deficiency is quite common in those with PCOS, and studies show that having normal vitamin D levels improves outcomes for both mother and baby during pregnancy. It also plays an important role in overall fertility and improves in-vitro fertilization (IVF) outcomes for those choosing that form of treatment. As mentioned above, vitamin D supplementation can improve menstrual cycle regularity in people with PCOS. Studies have also shown an increased likelihood of implantation and pregnancy in people with PCOS who have normal vitamin D levels. Given all of this, if you have PCOS and are concerned about your fertility, it may be helpful to speak to your doctor about checking your vitamin D levels to see if supplementation is right for you.

TLDR; N-acetyl cysteine (NAC) is an antioxidant that may help support fertility in those with PCOS, but more studies are needed. Vitamin D plays a key role in fertility, so check with your doctor to see if you need supplementation.

Blood sugar and insulin resistance

Insulin resistance (IR) occurs when the cells in your body (specifically in your muscles, fat cells, and liver) don’t respond as they should to insulin, the hormone responsible for helping your body use carbs for energy. Insulin resistance leads to higher blood sugars because your cells aren’t using the sugars from your food effectively. Because of this resistance, your pancreas starts producing more insulin, creating a condition known as hyperinsulinemia. This process can happen in people with PCOS, and can eventually lead to the development of type 2 diabetes and other health conditions. If you have PCOS and insulin resistance, your doctor will typically prescribe medications to help lower your blood sugars. But is there anything that can be done from a nutrition standpoint to support healthy blood sugar levels and manage insulin resistance?

General recommendations for managing insulin resistance (IR) in people without PCOS still apply, such as building a balanced plate with a source of whole grains (yes we still want to eat carbohydrates even if we have insulin resistance and high blood sugars), healthy fats, protein, and fruits or vegetables. Getting enough fibre and choosing forms of activity you enjoy is also important. Something you may hear from your doctor or other healthcare providers is that you must lose weight in order to manage your IR or blood sugars if you have PCOS. This may not be a helpful or realistic goal for some people with PCOS. Many women with PCOS will follow extreme diets or exercise regimens in order to lose weight - which can cause more harm than good, leading to nutrient deficiencies, and regaining the weight as soon as you ‘fall off the wagon’. A more helpful approach instead is to focus on nutrition and lifestyle changes that support your overall health and not a number on the scale. Your body weight may change, or it may not, it’s really hard to predict, but focusing on behaviours that are within your control is more likely to lead to long-term improvements regardless of how your body changes. (Psst - if you want more individualized help with managing things like insulin resistance through a weight-inclusive and non-diet approach, check out all the ways you can work with NutritionIQ here ). 

If you are curious about supplements that may help with managing blood sugars and insulin resistance, there are a few that show promising effects. As we’ve discussed, vitamin D has multiple positive effects for PCOS symptoms, and may also help with blood sugar management. Studies show that consistent, low-dose supplementation decreases fasting blood sugar and insulin levels. Another supplement we’ve mentioned before is melatonin - on top of its benefits for cycle regularity and sleep, it also contributes to managing insulin resistance and high blood sugar levels. Once again, these benefits are observed with long-term supplementation, so keep that in mind if you are interested in trying. Myo-inositol is another supplement with multiple benefits for PCOS management. Other than helping with cycle regularity, it has also been found to decrease fasting insulin levels with long-term supplementation. 

Coenzyme Q-10 (Co Q-10) is an enzyme present in cells in the heart, kidneys and liver. It is a powerful antioxidant and is also involved with energy production in cells. Studies show that supplementation can improve insulin sensitivity. One study found that 12 weeks of supplementation improved insulin levels and fasting blood sugars. There are minimal risks to supplementation, but as always, it’s best to ask your doctor or pharmacist before trying any new supplement. 

Lastly, people with PCOS tend to have less diverse gut microbiomes. Some studies show that probiotic supplementation in people with PCOS can help lower fasting insulin levels. However, you can also simply add foods to your day that are rich in fibre and probiotics to help support a diverse and rich gut microbiome. Fermented foods like yogurts, kefir, sauerkraut, tempeh, miso, kimchi, kombucha, and pickles are all great sources of probiotics. Fibre acts as a food source for good gut bacteria - so adding a bit of fibre to your meals can go a long way in promoting a healthy gut microbiome. 

TLDR; hormonal imbalances in PCOS contribute to insulin resistance and high blood sugars. Following general recommendations for healthy blood sugars is a great place to start. Try to focus on adding health-promoting habits, as opposed to weight loss. Some supplements, like vitamin D, melatonin, myo-inositol, and coenzyme Q-10 may also support healthy blood sugars and lower insulin resistance. Probiotics may also help manage blood sugars and insulin levels. 

Supplements with little evidence for PCOS management

In your search to find ways to manage PCOS through nutrition, you may have come across countless articles, videos, posts, or comments recommending various supplements as life-changing. We’ve highlighted a few with robust evidence, but we also wanted to mention a few that you may see online that have little evidence to back them up, and could be potentially harmful. 

Vitamins

In terms of vitamins, vitamin K, E, and A have been explored in the literature and may provide theoretical benefits to those with PCOS, however they can’t be routinely recommended as there aren’t many studies that support these claims. These vitamins are also what we call fat-soluble vitamins, so excess supplementation does carry some risk. Supplementation can only be recommended if you have a diagnosed deficiency or health condition that increases the amount that your body needs. 

Polyphenols

Another product often recommended online are bioflavonoids, polyphenols, or herbal supplements that contain these products. What are bioflavonoids and polyphenols, you may ask? These refer to molecules in foods or plants that give them their signature colour, and also have antioxidant properties, as well as other potential health benefits. While some have been shown to help with inflammation, there aren’t enough studies to recommend these to everyone with PCOS. Polyphenol supplements can be pricey, so they aren’t accessible to all. Plus, they are naturally found in the foods you eat, so chances are, you’re consuming some daily without knowing it.

Alpha-lipoic acid (ALA)

This is an antioxidant compound produced in the body, but also found naturally in red meat, beets, carrots, potatoes, spinach and broccoli. There are very few studies done on this supplement with people who have PCOS, so it can’t be routinely recommended. 

Carnitine

This compound is involved in metabolism, and studies show that people with PCOS may have lower levels of carnitine than the average person. It is found naturally in many foods (especially animal products) and our bodies produce it. Those who don’t eat animal products produce enough to meet their body’s needs. For those with PCOS, there are very few studies exploring it’s benefits, so it can’t be recommended.

Chromium picolinate

Chromium picolinate is a chemical compound that is essentially a supplemental form of chromium. It is a compound that is naturally found in many foods, such as meats, grains, vegetables, nuts, spices, brewer’s yeast, beer and wine, however the exact amounts may vary greatly depending on local water and soil conditions. The rate of absorption in our guts is quite low. Some studies show that supplementation has a beneficial effect on insulin resistance and overall blood sugar control in people with PCOS, however some studies did not observe any effect. It has been shown to increase insulin sensitivity in some populations. This compound has some potential to support healthy blood sugars, but more studies are necessary, so we can’t routinely recommend it. But, if you are interested in trying it, it may be worth discussing with a doctor or pharmacist as it can interact with other medications and could increase your risk of a low blood sugar.

Minerals

Some studies have explored the potential benefits of calcium, magnesium, zinc, and selenium for PCOS management. Magnesium, zinc, and selenium all have theoretical benefits when it comes to PCOS management, but there is a lack of research on all three of these minerals. They are often supplemented in combination with other vitamins or minerals in research, so their individual effects are difficult to establish. Calcium is often an addition to vitamin D supplementation, but on its own, it is unknown if there is a beneficial effect on PCOS symptoms. One important note is that excess selenium supplementation can cause selenium toxicity, and there is not enough evidence to recommend it. 

Lifestyle changes to manage PCOS symptoms

Now that we’ve discussed how nutrition can help with managing PCOS symptoms, let’s explore some simple lifestyle strategies that can help as well. 

Movement 

Any kind of physical activity or movement will have health benefits. The 2023 American Society for Reproductive Medicine guidelines suggest that adults with PCOS should aim for a minimum of 150 to 300 minutes of moderate-intensity activities OR 75 to 150 minutes of vigorous-intensity aerobic activity per week. They also recommend including muscle-strengthening activities (resistance or flexibility exercises like weight training, yoga, and body weight exercises) twice a week. They mention that greater health benefits are observed if you exceed these goals. Physical activity in PCOS has been shown to help with insulin resistance and blood sugar management, as well as mental well-being and androgen levels. Finding the time to add physical activity to your day, however, can seem daunting. We recommend choosing a form of activity you genuinely enjoy and slowly increasing the amount you do each week. Even short bursts of activity, to minimize the amount of time you are sedentary during the day are helpful - things like getting up from your desk to fill up your water bottle, or going on a quick walk on your lunch break if work allows are some ideas. It’s also important to note that any kind of movement that involves using your muscles counts. So, things like walking, physical labour at work, household chores, playing games with your kids, sports, and other daily activities all count. 

TLDR; try to incorporate forms of movement you enjoy into your daily life. Resistance exercise may be especially helpful when it comes to managing PCOS symptoms. 

Sleep

Studies find that women with PCOS are at greater risk of having both diagnosed sleep disorders and non-clinical sleep disturbances. This poor sleep quality is caused by the hormonal imbalances associated with PCOS. Those with PCOS are also at greater risk for obstructive sleep apnea (OSA), a condition in which you continuously stop and start breathing while asleep. Some signs of OSA include snoring, excessive daytime sleepiness, and waking up at night gasping or choking. As mentioned before, poor sleep exacerbates other symptoms of PCOS, like insulin resistance, mental health disorders, and hormonal imbalances. Optimizing your sleep is therefore a key aspect of managing PCOS symptoms. In terms of lifestyle management, if you have PCOS and have symptoms such as snoring, daytime sleepiness or extreme fatigue, consider bringing this up to your doctor or other healthcare provider. They can perform tests or refer you to a specialist to assess you for sleep disorders or OSA and provide the appropriate treatment. Otherwise, following good sleep hygiene practices can help promote better quality sleep. This resource from Harvard Stress & Development Lab is a great starting point. 

TLDR; people with PCOS tend to have worse sleep quality. Talk to your doctor about having your sleep assessed if it is interfering with your daily life. Follow good sleep hygiene habits to promote better sleep.

Body image, weight stigma and PCOS

People with PCOS tend to have worse mental health than their peers without it. They are at increased risk for anxiety, depression, and other mental health conditions. They are also at greater risk of body dissatisfaction and eating disorders. Researchers theorize that this may be due to the hormonal imbalances related to PCOS, as well as their related symptoms. Many of the symptoms experienced by women with PCOS can be stigmatizing, as they challenge what society considers traditionally ‘feminine’ - excess body hair, hair loss, acne, etc. For those with PCOS who are living in larger bodies, this stigma can be even worse. They may have their symptoms dismissed, ignored or downplayed, or be told that they must lose weight before being allowed to access certain treatments (in particular fertility treatments). Often, women with PCOS will be told by healthcare providers that the only thing they can do to manage their symptoms is to lose weight. This is simply untrue. PCOS is a complex syndrome, and exclusively focusing on weight is not the most helpful approach. 

The science shows that having a strong sense of self-esteem and self-compassion protects against body dissatisfaction and depression in those with PCOS. So, if you have PCOS, we encourage you to cultivate self-compassion and practice body respect. You can practice cultivating self-compassion with mindfulness exercises, breathing exercises, journaling, meditation, practicing gratitude, and changing your ‘self-talk”. Practicing body respect involves nourishing your body in a way that feels good, finding movement you enjoy, wearing comfortable clothes that fit your lifestyle, getting adequate rest, and anything that makes you feel like you are taking care of yourself.   Our advice is to choose a form of self-compassion that you enjoy and that fits into your lifestyle.

TLDR; PCOS can lead to worse mental health and can be stigmatizing. Cultivating self-compassion can improve your quality of life and have a positive effect on your mental health.

The bottom line on thriving with PCOS

Nutrition and lifestyle can play a role in managing PCOS symptoms. The science shows that certain foods and supplements can help with cycle irregularity, hormonal imbalances, fertility, and insulin resistance. Other lifestyle habits like movement, getting enough sleep, and self-compassion can also improve your quality of life and symptoms of PCOS. It’s important to know that if you have PCOS, lifestyle and nutrition changes that work for you may not work for another person - PCOS is highly individual and should be treated that way. If you suspect that you have PCOS, or if your PCOS symptoms are severe and interfering with your daily life, we encourage you to reach out to a healthcare professional. If you have PCOS or know someone who does, we hope that the information shared in this post will help you on your journey to thriving with PCOS. 

Looking for a helpful cheat sheet to help you manage your PCOS symptoms through food and lifestyle hacks? Check out our handy summary of tips, with the top sources of nutrients to help manage symptoms, recipes and even a BONUS section on Endocrine Disruptors!

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