Having PCOS (polycystic ovary syndrome) is not fun. At all. And if you're reading this and you don't have the syndrome, statistically speaking you know someone who does. The endocrinal syndrome affects 12-18 percent of women of reproductive age and up to 21 percent in some high-risk groups such as Indigenous women.
While there is no cure for PCOS, there are dietary and lifestyle changes people with PCOS can make which can significantly improve their symptoms.
To find out all about PCOS and what are the best diets and foods for managing the syndrome, HuffPost Australia spoke to three health experts working in the PCOS field.
What is PCOS and what are the symptoms?
"PCOS is a hormonal syndrome and can cause a variety of symptoms in different women, and not everyone has all of the symptoms," Kate Marsh, accredited practising dietitian, diabetes educator and director of PCOS Health, told HuffPost Australia.
"The common symptoms of PCOS are irregular periods, signs of excess male hormones (which can cause acne or excess hair on the face and other areas you wouldn't normally see a lot of hair growth), and some women also get scalp hair loss.
"It's not part of the diagnostic criteria of PCOS, but the majority of women with PCOS do struggle with their weight, so they tend to put on weight more easily and tend to store weight around their middle."
PCOS can affect fertility which is often how women first present with the syndrome. The syndrome also causes underlying metabolic issues.
"What we know is the underlying problem for most women with PCOS is insulin resistance, which is actually the same problem that occurs in type 2 diabetes," Marsh said.
"What happens is these women have insulin resistance and as a result their body produces extra insulin, and the high insulin acts on the ovaries and causes the increase in male hormones which causes the hormonal balance."
Insulin resistance also affects people's appetite which is another cause for weight issues for those with PCOS, accredited practising dietitian and DAA spokesperson Melanie McGrice told HuffPost Australia.
"Women with PCOS often have high insulin levels and that insulin resistance can impact their other appetite hormones to make them more hungry. This is the main factor that impacts weight gain."
A really integral part of lifestyle treatment is focusing on diet and physical activity.
The role of insulin in PCOS is what makes the syndrome a negative cycle.
"Insulin resistance means it's easier to gain weight, and if you gain weight you become more insulin resistance, so it becomes a cycle," Marsh said. "What this means is targeting and managing diet and lifestyle are so important."
Although not everyone with PCOS has insulin resistance, it's still important to ensure everyone with PCOS manages their weight and diet.
"Because PCOS is an 'umbrella' condition, to diagnose it we say the woman needs to have two out of three symptoms -- insulin resistance and high androgen hormones are symptoms but not all women with PCOS have these and those women don't tend to have weight problems," McGrice explained.
Diet and PCOS
There are some medications which can help manage insulin resistance and high androgen levels, but lifestyle changes should always be the first line of treatment, according to McGrice, Marsh and Lisa Moran -- Head of Healthy Lifestyle Research Program at Monash University, accredited practising dietitian and National Heart Foundation Future Leader Fellow.
"In the evidence-based guidelines for PCOS, which we are currently updating, we highlighted that lifestyle management should be first-line treatment for all women with PCOS before undertaking any medical treatment," Moran told HuffPost Australia.
"A really integral part of lifestyle treatment is focusing on diet and physical activity."
A healthy meal plan is also about thinking about improving insulin sensitivity and reducing diabetes risk in the long term.
There are many reasons diet and exercise can help manage PCOS, from reducing weight to managing stress levels (which both have an effect on insulin levels, thus reducing the risk of developing type 2 diabetes and cardiovascular disease), Moran explained.
"Weight and weight gain really should be prioritised.
"All women tend to have challenges with gaining weight a little bit every year, even if it's half a kilo or a kilo. If you can have a healthy lifestyle as early as possible to prevent that weight gain, you can really improve the features of PCOS."
If you're worrying about the idea of losing weight, even moderate weight loss can have significant health benefits, including improved mood and fertility, more regular menstrual cycles and a reduced risk of diabetes. Even if weight isn't currently an issue within your PCOS diagnosis, it's still important to follow a healthy diet and lifestyle.
"Weight is a big part of it and losing weight helps, but not all women with PCOS are overweight," Marsh said. "Even women with PCOS who aren't overweight still are more likely to have insulin resistance. A healthy meal plan is also about thinking about improving insulin sensitivity and reducing diabetes risk in the long term."
What is the best diet for PCOS?
One of the most frustrating things about PCOS is how under-researched it is. While there is scientific data about PCOS-related conditions such as insulin resistance, there is limited quality data on whether there are specific effective diets for PCOS. In saying this, there are clear dietary guidelines which significantly help reduce weight and manage symptoms.
"[Diet and PCOS] seems to be overlooked in research funding which means we have to do the best we can, but we don't have the same resources to work with," Moran said.
Here are five dietary tips for those with PCOS to follow.
1. Choose the right carbs (and the right amount)
One of the most important factors in the area of diet and PCOS is the quality of carbs.
"Where there's some research in PCOS, which we hope to expand on, is focusing on the quality of carbohydrates and the quality of fats," Moran explained.
This doesn't mean cutting out carbs completely (more on this soon), but you may need to lower your percentage intake of carbs -- under the supervision of a healthcare professional.
"A lot of women think they need to cut out carbohydrates and they don't -- it's about choosing the right types of carbohydrate and spacing them over the day," Marsh said.
"Particularly focus on lower GI foods like fresh vegetables, fruits, quinoa, legumes, barley, grainy breads and oats, and less processed carbohydrates."
2. Eat healthy fats
Like processed high GI carbohydrates, saturated fats can have a negative impact on weight and PCOS.
"Limiting saturated fat is important," Marsh said. "There's a lot of controversy about fat but we do know that saturated fat does worsen insulin resistance and increases diabetes risk.
"So we're not talking about low-fat but minimised saturated fat and choosing healthy fats from nuts, seeds, avocado and extra virgin olive oil."
McGrice also recommends including omega-3 fats found in oily fish like salmon and trout.
"One of the most important things is to have a low GI diet, but there are certainly particular foods which can help. Research tells us having an adequate intake of omega-3 fatty acids can have a positive impact on PCOS," McGrice said.
3. Limit red meat and processed meats
Protein is important for building new cells, perform basic bodily functions and aid with satiety, but not all protein is created equal.
"Looking at types of protein is important as well. There is evidence that high intake of processed meat and red meat can increase diabetes risk, so I would encourage women to include fish and plant proteins like legumes and tofu," Marsh said.
4. Reduce takeaway and junk food
Not surprisingly, the foods which are high in saturated fats and high GI carbs are those which fall under the 'takeaway' and 'junk food' categories.
"Women with PCOS should shift the focus back to homecooked meals using the core food groups like vegetables, whole grain breads and cereals, fruit and quality sources of protein and calcium," Moran said.
"This means having less takeaway foods and making sure our 'sometimes' are actually sometimes foods (not the bulk of our diet). With all Australians, processed foods and snack foods are making up a huge proportion of our diet and this would be the case for PCOS too."
5. Make diet and exercise a priority
We're all busy and we all have important things to do, but it's especially important for those with PCOS to make diet and exercise a priority.
"Keep track of yourself from year to year -- make sure your clothes aren't getting too tight, make sure you're not cutting back on exercise or making it a lower priority, and make sure your diet isn't changing from year-to-year as other life challenges change. Just keep track of yourself and make sure you're prioritising your health always," Moran said.
This goes for women with PCOS who have children or want to conceive.
"It's important to work with women with PCOS at a younger age at improving their diet. Women who are younger might have more conflicting priorities -- they're focusing on their family and put their own health at a lower priority," Moran said.
"We know that women who are in their 20s and 30s actually are at a higher risk of gaining a little bit of weight every year, which adds up over 10-20 years and can have a huge impact."
On top of thinking about what food you put in your mouth, Marsh recommends focusing on portion sizes, mindful eating and sleep.
"Spacing food over the day, looking at portion sizes, eating habits and mindful eating, in conjunction with the right exercise program, getting enough sleep and managing stress levels, are all part of managing PCOS. These can all impact on insulin," Marsh said.
"It's about tackling the syndrome from all directions to get the best outcome and get their insulin down."
Have a support network
Having PCOS can feel like an isolating syndrome, but you're not alone. To help create a positive support system, regularly check in with your healthcare team (from GP and dietitians to counsellors or complementary or natural therapies). If it helps, talk about your experience with those around you and find people who are going through the same experience.
"It's important to note that because it's a chronic condition, the government has allocated Medicare rebates for women with PCOS to see dietitians, so they just need to ask for a referral from their GP, and they should be able to get Medicare rebates. Not a lot of women with PCOS know this," McGrice said.
The ketogenic diet for PCOS?
Adopting a ketogenic diet has become popular for those with PCOS. While a lower carbohydrate diet can be very helpful in the management of PCOS, the three health experts explained there is insufficient good-quality evidence to show a strict low-carb diet works in the long term.
"Any restrictive diet is going to result in weight loss and in the short term this may provide some benefits, but if we look at long-term health I don't think there's enough evidence to say this is a good solution," Marsh said."
Restricting carbohydrates in the long term may also have negative impact on gut health.
"There's evidence now emerging on the impact of diet on our gut microbiome and the impact of those gut bacteria on our metabolic health, and a low-carb or low-grain diet which is high in animal foods and saturated fats have negative effects on your gut bacteria, which can potentially increase disease risk down the track," Marsh said.
"I'm more about focusing on sustainable changes women with PCOS can make for the long term."
And if you still decide to follow a very low-carbohydrate diet, you "absolutely want to do this with a health professional", Moran said.