syndrome in the future. Maternal obesity also increases the baby’s risk of developing childhood obesity and PCOS.
Women with type 1 diabetes who are being treated with insulin are also at risk of PCOS, with an estimated 18.8 percent34 to 40.5 percent35 affected, compared with only 2.6 percent in the control group. PCOS is six to 15 times more common among women with type 1 diabetes, probably due to the frequent high dosage of insulin.
Women with PCOS should be screened for type 2 diabetes using an oral glucose tolerance test every three to five years. Measuring fasting glucose alone may miss the diagnosis of up to 80 percent of prediabetic patients and 50 percent of diabetic patients. If cardiovascular risk factors exist, the screening should be done annually so the disease can be diagnosed at an early stage when lifestyle measures such as dietary changes can prevent damage to the body’s major organs.
» Metabolic syndrome
In 1988, Dr. Gerald Reaven of Stanford University termed syndrome X as a group of conditions with an unknown common factor, “X.” These conditions included central obesity, high blood pressure, high triglycerides, and high blood glucose. Reaven and Dr. Ami Laws (also of Stanford University) published the book Insulin Resistance: The Metabolic Syndrome X36 linking insulin resistance to metabolic syndrome and calling it the common factor in all these seemingly separate conditions.
In 2002, a National Institutes of Health report37 defined a patient as having metabolic syndrome if three of the following five conditions are present:
·Abdominal obesity: over 40 inches (102 centimeters) for men; over 35 inches (89 centimeters) for women
·High blood glucose: over 100 milligrams/deciliter (mg/dL), or taking medication
·High triglycerides: over 150 mg/dL, or taking medication
·Low high-density lipoprotein (HDL): below 40 mg/dL for men, below 50 mg/dL for women, or taking medication
·High blood pressure: over 130 mmHg for the systolic (top) number, over 85 mmHg for the diastolic (bottom) number, or taking medication
General obesity, albeit commonly associated, is not one of the criteria. Approximately 25 percent of metabolic syndrome patients are non-obese individuals. Interestingly, high low-density lipoprotein (LDL or “bad” cholesterol) is also not a criterion, even though many doctors and professional guidelines obsess about LDL and statins.
The prevalence of metabolic syndrome in the adult American population is now estimated at 88 percent38—leaving only 12 percent as metabolically healthy—and this comes with an increased risk of cardiovascular disease, stroke, cancer, NAFLD, obstructive sleep apnea, and PCOS.
The link between metabolic syndrome and insulin resistance makes it a reversible dietary condition, not a chronic progressive disease.
UNDERSTANDING THE LINK BETWEEN PCOS AND ITS ASSOCIATED RISKS
PCOS MUST BE considered more than merely a disorder of excess facial hair, acne, and abnormal reproduction. Patients with PCOS have double the chance of being hospitalized compared with those without the disease. The United States spent an estimated $4 billion in 2004 on health care related to treating PCOS39—an amount equal to the entire gross domestic product of Barbados. Much of this cost (40.4 percent) is due to the associated type 2 diabetes.40
Even more sobering, this number likely underestimates the true costs, because it takes into account only the reproductive years and not the associated health risks such as type 2 diabetes, heart attacks, strokes, and cancer that may arise in the future. These diseases typically occur in a woman’s post-menopausal years and are many, many times more expensive than simply treating PCOS.
Furthermore, PCOS is one of the main causes of infertility, which often leads to women seeking in vitro fertilization (a multi-billion-dollar industry). As we’ve seen, women with PCOS who do become pregnant are at increased risk of obstetrical complications such as gestational diabetes, pregnancy-induced hypertension (high blood pressure), and pre-eclampsia.
Though they are not part of the formal definition of PCOS, obesity leading to metabolic syndrome and insulin resistance leading to type 2 diabetes have been frequently noted in patients and affect an estimated 50 to 70 percent of women with PCOS. The close link to obesity and type 2 diabetes suggests that all three conditions have the same underlying root cause. All three are now understood as metabolic diseases, putting women with PCOS at high risk later in life for cardiovascular disease, strokes, and cancer.
Perhaps the most important associated disease is a history of weight gain that often precedes the diagnosis of PCOS. Of the obese women referred to one clinic, 28.3 percent were diagnosed with PCOS.41 PCOS can be more common as severity of the obesity increases, but more importantly, weight loss has also been proven to reduce testosterone, improve insulin resistance, and decrease hirsutism (more on this later).
Figure 3.1. The three metabolic diseases have a root cause
PCOS, obesity, and type 2 diabetes are variable manifestations of the same underlying problem. But what is that problem? To start answering this question, we need to know what causes obesity. Once we figure that out, we can gain a clue as to the root cause of PCOS.
GABRIELLA
Gabi’s story is a simple, clear-cut case of PCOS, but there’s always a twist. In early 2016, Gabi decided to start a family. She had been dating Hugo for many years, and now they were going to marry. She stopped taking the birth control pill, which she had used consistently since age 18.
Once off the pill, Gabi did not have a period for many months. For the first time in her life, she developed acne, and she also gained 8 pounds (4 kilograms). Gabi saw her doctor for a check-up, expressing her concerns. Besides her weight gain, she had headaches that lasted for days and that she could manage only by taking painkillers constantly. Her bloodwork showed increased androgen (male hormone) levels, which explained the acne and missed periods. An internal ultrasound confirmed multiple small ovarian follicles and the diagnosis of PCOS. Her doctor informed her it would be difficult to get pregnant, though not impossible. She felt devastated and discouraged.
At this point, Gabi asked for my help. She had been my patient and friend in Mozambique since 2009, and she knew I’d experienced the same situation. Like me, Gabi was a young, thin woman with PCOS. At 138 pounds (62 kilograms) and 5 feet 6 inches (1.7 meters) tall, she had a BMI of 23, which was perfectly normal. I reassured her that PCOS is a reversible condition related to hyperinsulinemia and insulin resistance and that the treatment was changing her diet. We discussed the diet of low-carbs and high healthy fats, which she knew from South Africa as the Banting Diet. She started immediately.
The next month her menstrual cycle went from 73 to 56 days. Considering that a normal menstrual cycle comes every 25–30 days, she had improved tremendously, but there was still work to be done. In just one month, her headaches were nearly gone, she stopped taking painkillers, and her skin cleared up. After two months on the new diet, Gabi felt less bloated, finally lost some weight, and started to ovulate. She continued on the low-carb diet and stopped snacking completely, even on “low-carb-friendly” foods. She also began some 24-hour intermittent fasting.
By January 2017, just over four months into her new way of eating, Gabi’s menstrual cycle had almost completely reverted to normal. Almost. She was late by a couple of weeks. Out of curiosity, she did a urine pregnancy test, which came out positive. She did a blood test right away. In Mozambique, doing a blood test is as easy as driving to the lab, ordering the test, and paying for it. This test, which is meant to be more accurate than the urine test, came back negative. She was devastated.
But something was not right. Her breasts were swollen and she had serious back and muscle cramps. Two other urine pregnancy tests were positive. We were worried. Could it be an ectopic pregnancy? Did she have a miscarriage? The very next day, she was able to get an appointment in nearby