I have a 27 year old client with polycystic ovarian syndrome (PCOS) who wants to improve her cardiovascular fitness and the shape of her legs. She manages her PCOS through diet and exercise. She is not overweight, although she has a small amount of excess body fat (enough to keep her feminine shape). She used to go to the gym as a teenager, and she did a lot of bench presses. As a result, she claims she got quite big shoulders, which she says is due to the elevated testosterone levels associated with PCOS. I’ve tried to reassure her and all of my female clients that they can work hard and gain definition but still retain their femininity. Is this untrue in the case of someone with PCOS? If so, how should I adapt my training program to ensure the client retains her feminine shape?
Here are some thoughts for you to consider and look into:
- Insulin resistance and hyperinsulemia appear to have a relationship with androgen hormonal modulation. There is more and more research linking high insulin levels to PCOS. The research shows that high circulating insulin stimulates certain ovarian enzymes, resulting in elevations in testosterone (both free and serum). Insulin influences the androgenic state by affecting metabolism of ovarian androgens but also by regulating circulating levels of sex hormone binding globulin (SHBG). Insulin has been show to lower SHBG (which binds to estrogen and testosterone, making them unavailable. Thus, lowered SHBG increases the bioavailability of testosterone to the tissues = PCOS symptoms).
- Women who are estrogen dominant (low progesterone levels) have been shown to have high circulating insulin and cortisol levels. This has been shown to be a precursor, as well as a correlating factor, to developing PCOS.
- Women who have chronic depression and anxiety have been shown to develop PCOS.
How do you work with this? Here is what I would do:
- I would focus on a 100 percent rule with your client and nutrition and lifestyle principles. No 80/20 at this point. I would put her on mainly a protein type diet, eliminating all gluten, flour, sugar, etc. I would also try to make the diet more on the fungal diet side as well. This will increase her fat and protein intake and limit the amount of carbs and fruit she is eating, thus helping to regulate blood sugar levels.
- I would run a full hormone profile (#207* or #209) on her to find out where she is at. Then you can supplement with bio-identicals as needed.
- I would run an adrenal profile (#201) as well. With any type of stress, there is an increase in CRH (which can drive clinical depression), elevated cortisol levels and androgen production. High cortisol levels raise blood glucose levels. High persistence glucose levels lead to excessive insulin secretion. Excess insulin secretion leads to insulin resistance. With insulin resistance, there can come more pancreatic production of insulin in order to compensate for the resistance. These high cortisol and insulin issues lead to Syndrome X, weight gain, difficulty with weight loss, depression, anxiety and so forth.
- This client's situation is a prime example of the many pieces to the healing puzzle. It is also important to know what order to put them in. With this client, exercise right off the gate will put more fuel to the fire. I would start with nutrition and lifestyle principles, labs, etc, then one to three months down the line, when her sympathetic nervous system, hormonal system, digestive system and immune system start to cool down, you can add in an exercise program to meet her physiological load/needs at that point in time. It is not the exercise that is making her “bulk” up. It is her altered physiology. You know if an exercise program or plan of attack is the right choice if it decreases pain, weight, increases digestion, increases a person’s overall well being and meets their needs. You know if an exercise program, etc is not a good choice if you get the opposite result! Assess, don’t guess. Refer out if needed, and realize we all have different pieces to the healing puzzle. As well, theses pieces need to be organized in the correct fashion to meet each client’s individual needs.
I hope this gives you some direction.
* These numbers refer to specific adrenal/hormone lab tests from Biohealth. You can refer your client right to BioHealth, and they can do a lab with a Functional Medicine MD. For more, visit www.biodia.com (practitioners) and www.biohealthinfo.com (for clients).
- Jones, David S. MD, Editor-in-Chief. Textbook of Functional Medicine. Institute For Functional Medicine. 2008.