PCOS/PMOS – Naturopathic Care for Fertility in Toronto

PCOS (Polycystic Ovarian Syndrome)

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

Recently renamed Polyendocrine Metabolic Ovarian Syndrome (PMOS), Polycystic Ovarian Syndrome is a condition where ovulation is either irregular or absent.  There are a number of reasons why this can occur; the most common, but not the only, reason is androgen (male hormone) excess.  This type of polycystic ovarian syndrome, or what I would call “classic”, occurs in about 60% of all women with the condition.  The remaining 40% (non-classic PCOS) will have a variety of other hormone imbalances that are interfering with ovulation.

The PCOS Phenotypes: Why Your Type Matters

PCOS is diagnosed using the Rotterdam Criteria, which require two of the following three features: irregular or absent ovulation, clinical or biochemical signs of androgen excess, and polycystic ovarian morphology on ultrasound.¹ Polycystic-appearing ovaries alone, without hormonal evidence, do not constitute a PCOS diagnosis.

This three-feature framework produces four distinct phenotypes with meaningfully different hormonal profiles, metabolic risks, and treatment requirements:

Phenotype A (Classic, Full):

Anovulation + androgen excess + polycystic ovaries. The most common and metabolically significant presentation. Highest risk of insulin resistance, dyslipidemia, and cardiovascular disease.

Phenotype B:

Anovulation + androgen excess, without polycystic ovarian morphology on ultrasound. Hormonally similar to Phenotype A; ovaries may appear normal despite significant androgen excess and anovulation.

Phenotype C (Ovulatory PCOS):

Androgen excess + polycystic ovaries, with ovulation present. Fertility may be less impaired, but androgen-driven symptoms (acne, hirsutism, hair loss) are prominent. Often missed because cycles are regular.

Phenotype D (Non-Androgenic):

Anovulation + polycystic ovaries, without androgen excess. The mildest metabolic risk profile. Often driven by thyroid dysfunction, hyperprolactinemia, or low body weight/hypothalamic suppression — which is why thorough testing is essential rather than assuming all PCOS is the same.

Knowing your phenotype determines which treatment levers are most relevant. Applying a Classic PCOS insulin-lowering protocol to a Phenotype D patient with non-androgenic PCOS and a thyroid problem produces poor results. This is why I test before treating.

What Causes PCOS?

It depends on which type of polycystic ovaries you mean.  In the “classic” form, where androgen levels are high, insulin triggers excessive androgen production by the ovaries and/or adrenal glands. In “non-classic,” there can be undiagnosed hypothyroidism or Hashimoto’s, high or low estrogen, high prolactin, high stress or low body fat. Thorough blood testing is essential to understand which factors are contributing to a lack of ovulation.

Signs and symptoms

In Classic PCOS, some, many, or all of these signs and symptoms may be present:

• high or high-normal DHEAs, testosterone, DHT and/or androstenedione
• acne
• head hair loss
• excessive facial or body hair (hirsutism)
• irregular or absent periods
• heavy, painful periods
• anxiety, depression, irritability
• PMS/PMDD
• insulin resistance
• weight gain or difficulty losing weight (although some women with insulin resistance are thin)
• dysglycemia
• cysts on the ovaries on ultrasound (these do NOT have to be present to have polycystic ovarian syndrome)
• often a family history of cardiovascular disease and/or diabetes
• infertility

Because there is a variety of factors that cause non-Classic PCOS, the symptoms are more variable:

• irregular or absent periods
• cysts on the ovaries on ultrasound (may or may not be present)
• acne
• anxiety, depression, irritability
• There may be an absence of androgen-induced symptoms such as head hair loss, excessive body hair and acne
• may be of any weight/size
• infertility

What I Test for in PCOS – and Why Standard Bloodwork Often Isn’t Enough

As a naturopathic doctor with a background as a hospital medical laboratory technologist, I interpret PCOS bloodwork with reference ranges calibrated for fertility optimization, not just the detection of overt disease. Here is what I assess and why each marker matters:

Fasting insulin and HOMA-IR:

The most important test in Classic PCOS that most GPs don’t order. Insulin resistance can be present with an entirely normal fasting glucose – which means a fasting glucose, or even an HbA1c, can be normal while insulin is driving excessive androgen production from the ovaries. HOMA-IR above 2.0 suggests insulin resistance clinically relevant to PCOS pathophysiology; many labs don’t flag it until it’s considerably higher.

Full androgen panel:

Testosterone alone is insufficient. I measure total testosterone, free testosterone (or calculated from SHBG), DHEA-S, androstenedione, and DHT. The pattern across these markers identifies whether androgen excess is primarily ovarian, adrenal, or both, which changes the treatment approach. SHBG is also measured because low SHBG increases the proportion of free, biologically active testosterone even when total testosterone appears normal.

Full thyroid panel:

TSH, free T3, free T4, reverse T3, anti-TPO antibodies, anti-thyroglobulin antibodies. Thyroid autoimmunity is more prevalent in women with PCOS than in the general population and can cause anovulation and polycystic-appearing ovaries independently of androgen excess – the non-classic presentation.² TSH alone misses this.

LH:FSH ratio:

An LH:FSH ratio above 2:1 is a classic finding in PCOS. It reflects the abnormal GnRH pulse frequency that drives excess LH secretion relative to FSH, contributing to androgen production and impaired follicular development.

Prolactin:

Elevated prolactin suppresses GnRH pulsatility and can cause anovulation and cystic-appearing ovaries. This is a PCOS mimic that requires a completely different treatment approach. Prolactin should be measured correctly: after 20 minutes of seated rest, as stress acutely elevates prolactin.

Estradiol:

Both high and low estrogen can contribute to non-classic PCOS presentations. Chronically elevated estrogen without adequate progesterone opposition drives endometrial proliferation and increases long-term endometrial cancer risk, an underappreciated consequence of anovulatory cycles that is relevant in all PCOS phenotypes.

AMH (Anti-Müllerian hormone):

AMH is typically elevated in PCOS, often substantially, reflecting the large number of small antral follicles present. Very high AMH in the context of PCOS does not mean good fertility; it reflects follicular arrest rather than follicular abundance. It also predicts a high risk of ovarian hyperstimulation syndrome (OHSS) in IVF cycles, which is important information for your reproductive endocrinologist.

25-OH Vitamin D: Vitamin D deficiency is significantly more prevalent in women with PCOS than in the general population and is associated with more severe insulin resistance, higher androgen levels, and worse metabolic markers in PCOS independently of BMI.[^3] It is also frequently deficient in Ontario given our latitude.

Homocysteine: Elevated in women with PCOS, particularly those with insulin resistance and MTHFR polymorphisms. Relevant for both cardiovascular risk and for the higher miscarriage rates seen in PCOS pregnancies.

HbA1c and fasting glucose: Baseline metabolic markers. Women with PCOS have a four- to seven-fold increased lifetime risk of type 2 diabetes — tracking glycemic markers from the point of diagnosis establishes a baseline and identifies those already trending toward impaired glucose tolerance.

What is the conventional PCOS treatment?

For women who are not trying to conceive, doctors will prescribe birth control pills to provide an artificial menstrual cycle and manage some of the symptoms. Spironolactone may also be prescribed as an anti-androgen.  Metformin may be prescribed for women who are trying to conceive, and it may help because it helps to lower insulin levels.  Clomid or Letrozole is often the first-line medication for women with polycystic ovaries who are trying to conceive. If that fails, then injectables and IVF may be recommended. In my experience, women with PCOS who choose to tackle it with natural treatment can conceive on their own without medical intervention.

What is the naturopathic PCOS treatment?

Naturopathic treatment for PCOS is tailored to the individual and to their particular type of hormone imbalance.

Classic PCOS Treatment

To treat the Classic version naturally:

1. Reduce insulin requirements to reduce high androgens. Diet, stress reduction, and exercise are all important for lowering insulin and, therefore, reducing androgens.
2. Improve insulin sensitivity. Reducing inflammation and natural treatments such as cinnamon, zinc, inositol, exercise, and N-acetylcysteine improve insulin sensitivity.
3. Help with weight loss. Losing even 10% of your body weight can improve fertility and reduce PCOS symptoms. Regulating blood sugar levels and reducing insulin, in turn, helps with weight loss and burning body fat.
4. Block the male hormones with anti-androgen herbs. Herbs such as spearmint, saw palmetto, pygeum, nettle root, and green tea have anti-androgenic properties.
5. Stabilize your blood sugar. Minerals like chromium and vanadium, and herbs like banaba leaf, holy basil, and fenugreek, help stabilize blood sugar, which helps curb carb and sugar cravings.
6. Balance female hormones. Support normal estrogen production with vitamins, minerals and herbs like peony, support normal progesterone production with herbs like Vitex.
7. Enhance fertility by lowering androgens and balancing estrogen and progesterone.
8. Optional acupuncture to enhance fertility.

Non-Classic PCOS Treatment

1. Treat the underlying hormone imbalance – support normal estrogen levels, lower high prolactin
2. Help with stress reduction
3. Help with adopting an appropriate diet to maintain a healthy body weight.
4. Support the normal functioning of the entire endocrine system – ovaries, adrenal glands, parathyroid, thyroid, hypothalamus, pituitary, pineal, pancreas, thymus gland.
5. Optional acupuncture to normalize the function of the endocrine system and enhance fertility.

PCOS Research

These are just a couple of studies that demonstrate the benefit of naturopathic treatment for Polycystic Ovarian Syndrome.

PCOS, BMI and Fertility

A study looking at the connection between body mass index (BMI) and fertility found that a higher than normal BMI was an independent negative factor for many aspects of fertility. These negative effects were more profound in those with severe obesity and with PCOS.   Source: The effect of female body mass index on in vitro fertilization cycle outcomes: a multi-center analysis. 2018.  Journal of Assisted Reproduction and Genetics, 1-11.

Acupuncture, TCM and PCOS

In a randomized controlled study, 60 patients were assigned to a control or observational group where they were given acupuncture combined with Chinese medicine for 3 cycles. Acupuncture combined with Chinese medicine was found to improve the endocrine levels and insulin resistance of PCOS as well as increased pregnancy rates.  Source: [Acupuncture and Chinese medicine of artificial cycle therapy for insulin resistance of polycystic ovary syndrome with phlegm damp type and its mechanism]. Zhongguo Zhen Jiu. 2017 Nov 12;37(11):1163.