Supplemental Recommendations for Individuals with PCOS

Both nutritional and supplemental interventions can have a significant impact on the symptoms associated with PCOS. Women with PCOS are commonly deficient in vitamins and minerals. ^{1 2} Gathering and assessing blood work as well as discussing specific symptoms with your doctor will enable more personalized supplemental recommendations. Below are some supplements we may recommend to our patients. We encourage you to discuss these options with your doctor so the supplements and dosing can be personalized to your specific needs and appropriately monitored. 

VITAMINS AND MINERALS

Vitamin D

• 67-85% of women with PCOS have a vitamin D level below 20 ng/ml. ³
• Healthy levels of vitamin D support weight loss, ovarian follicle maturation, ovulation, menstrual regularity and reduction in androgen (“male” sex hormones) levels as well as total testosterone, healthy carbohydrate metabolism, glucose balance, and progesterone production. ⁴
• Vitamin D can also support a reduction in insulin resistance and can promote insulin sensitivity. ⁵
• While NIH considers Vitamin D level >=20 ng/mL to be adequate, many physicians, including integrative and functional medicine physicians will often aim for a higher optimal range as it supports a healthy immune function, may reduce the risk of rheumatoid arthritis and cancer, and helps to prevent deficiency. This optimal range is often considered to be between 40-70 ng/mL. ^{6 7}
• Depending on the formulation, Vitamin D is often taken with a meal containing fat to enhance absorption. Certain formulations may be recommended to be taken on an empty stomach. Be sure to clarify with your doctor and read the label and directions of your supplement. 

Zinc 

• It is common for women with PCOS to have lower serum levels of zinc and this may play a role in the pathogenesis of PCOS. ⁸
• Zinc plays a role in glucose metabolism, has anti- androgenic effects, can help decrease hirsutism, can help reduce oxidative stress, supports lipid metabolism, and may lower inflammation. ⁹

Chromium 

• Chromium helps to improve fasting insulin, decrease free testosterone, support weight loss, while also helping to curb postprandial glucose spikes (glucose spikes after a meal).
• Chromium plays an important role in insulin activity, can help reduce insulin resistance and can improve blood glucose control. ¹⁰
• Chromium picolinate is the optimal form to use and one meta-analysis showed supplementation with chromium lead to a decrease in BMI, fasting insulin, and free testosterone in those with PCOS. ¹¹

HERBS AND SPICES

Chaste Tree Berry (also known as Vitex)

• Chaste tree berry can be a wonderful supplemental intervention to help with menstrual regularity, PMS symptoms, painful periods, breast pain, and infertility which are all often associated with PCOS. ¹²
• Chaste tree berry acts on the pituitary gland and increases LH as well as progesterone, therefore shifting the estrogen-progesterone ratio to be more favorable. Vitex has a progesterone-like effect and has been found to be a useful herb when trying to normalize an irregular menstrual cycle. ¹³
• Specific blends of vitamins, green tea, l arginine, and chaste tree and have been shown to improve fertility and increase pregnancy rates. ¹⁴
• It is important to remember that it takes time to see the benefits of chaste tree, you need to work with your doctor to determine the appropriate length of time to use but it is generally recommended to use for a minimum of three months. 
• Chaste tree is not optimal for all women with PCOS, specifically those with elevated levels of luteinizing hormone, we recommend you have this checked before considering supplementation.
• If supplementing with chaste tree to support healthy ovulation, it is recommended to start taking it early in the follicular phase. 

Green Tea

• Green tea in the form of loose leaf or matcha contains l-theanine which has been shown to improve mood, cognition and reduce stress and anxiety ^{15 16}, all of which are common in women with PCOS. 
• Green tea can be a coffee alternative to those who are more sensitive to coffee or are trying to decrease their coffee intake. 
• Green tea has been shown to support weight loss, lower free testosterone and lower fasting insulin in those with PCOS. ¹⁷
• There is also research showing potential benefits to supplementing with green tea extract which can lead to a reduction in testosterone, however no long-term data is available to determine efficacy and safety. ^{18 19}
• For our patients who use the supplemental form of green tea (green tea extract) regularly, we typically monitor liver enzymes as there have been reports of liver injury in the literature. ^{20 21}

Licorice

• Licorice has well documented antioxidant and antifatigue properties and can strengthen our ability to handle bacterial and viral infections. ²²
• Licorice has been looked at as a possible intervention to support those with infertility and PCOS due to its estrogen activity and capabilities. ²³
• In some individuals, licorice can be an effective intervention for reducing excess testosterone as it blocks the conversion of androstenedione to testosterone. Licorice is considered an androgen antagonist due to its ability to block androgen receptors, the conversion of androgens, and reduce androgen production. ²⁴
• One clinical trial found that in young, healthy women taking 3.5g daily of licorice over two menstrual cycles, total testosterone was reduced.  ²⁵
• When taking licorice remember to discuss the form with your doctor: pill, tincture, tea etc. and to ensure your blood pressure is monitored (especially if you have a history of high blood pressure) as well as that your electrolytes are monitored. 

Cinnamon

• Cinnamon is well documented at being supportive for those with hyperglycemia and insulin resistance. ²⁶
• In one study, researchers found that cinnamon supplementation was as effective as metformin (taken at 500mg three times daily) at reducing insulin resistance as well as testosterone levels. ²⁷
• When using cinnamon in cooking or baking, if possible, try to use Ceylon cinnamon as opposed to cassia cinnamon (most cinnamon that is labelled cinnamon is cassia cinnamon). Ceylon cinnamon is more effective at supporting blood sugar control, can support healthy cholesterol levels and is much lower in coumarin. It is important to consider coumarin as consuming it at high levels can be harmful to the liver. ²⁸

Curcumin

• Turmeric is an effective herb for reducing oxidative stress, due to the anti-inflammatory and antioxidant properties of the compound curcumin. Consumption of turmeric can positively impact lipid levels and insulin levels. ²⁹
• Curcumin has also been shown to support increased glucose absorption by skeletal muscle and also reduces endogenous glucose production. ³⁰
• Curcumin is not easily absorbed into the bloodstream. To enhance absorption, it is typically recommended consuming it with a healthy fat as well as black pepper. That being said, curcumin improves intestine barrier function and affects the gut microbiome, so much of its action is actually at the level of the gut. 

Berberine

• Berberine is commonly used in individuals who struggle with hyperglycemia and insulin resistance.
• Berberine is a plant compound found in the bark, leaves, twigs, roots, and steam of plants within the Berberidaceae family which include Goldenseal, Oregon grape, tree turmeric, California poppy and barberry. Additionally, it is important to note that goldenseal is on the threatened or endangered plant list in many states across the United States so please do not use it unless absolutely necessary. ³¹
• Berberine also promotes glucose uptake, reduces intestinal absorption of glucose and cholesterol, and can improve fertility and pregnancy outcomes in women with PCOS. ³²
• Berberine and metformin are similar in their abilities to improve glucose uptake and weight/BMI; furthermore, berberine has been shown to lower lipid levels. ^{33 34}

Spearmint tea

• Spearmint tea has anti-androgenic effects and therefore helps to lower testosterone levels and reduce hirsutism.  ^{35 36}
• Spearmint can help to restore follicular development in ovaries as well as help to increase luteinizing hormone (LH), follicle-stimulating hormone (FSH), and estradiol (E2). 
• While research suggests 2 cups of spearmint tea (warm or cold) daily for the greatest benefits, it is not recommended if you have acid reflux or are breastfeeding. ³⁷

OTHER SUPLEMENTS TO CONSIDER

Inositol (Myo and D chiro)

• Inositol has been shown to help with ovulation, increased pregnancy rates in women undergoing ovulation induction, reduce male sex hormones, and improve insulin sensitivity.
• Inositol can be an alternative to metformin as it helps with insulin sensitivity. ³⁸
• For inositol supplementation we recommend is: 2g 2x daily (a combination of myo and D chiro inositol is optimal with a ratio of 40:1). ³⁹

NAC (N-acetylcysteine)

• NAC is used for its antioxidant and anti-inflammatory properties it can also help increase concentrations of glutathione, another powerful antioxidant 
• NAC supplementation (600mg three times daily) in one study, was shown to improve pregnancy outcomes as well as ovulation rates when compared to a placebo. ⁴⁰
• A systematic review and meta-analysis found that NAC improved metrics associated with PCOS including elevated body weight, fasting insulin and glucose, total cholesterol, and triglycerides. ⁴¹

Omega 3 Fatty  Acids

• Consumption of omega-3 fatty acids helps decrease inflammation, lowers waist and hip circumference, balances and corrects lipid profiles, and helps to lower fasting blood sugar. ^{42 43}

• Omega 3 fatty acids have also been shown to support menstrual regularity as well as PMS symptoms such as anxiety, depression, lack of concentration, bloating, headache, and breast tenderness.  ⁴⁴
• We can get Omega 3s from our diet, however in certain cases additional supplementation is required. Dosing and type should be discussed with your doctor. There may be an increased bleeding risk at dosages >=4g per day and in general it is recommended to stop taking one week prior to surgery or invasive procedure. 
• Rich sources of Omega-3s
  • Foods Rich in ALA include: flax seeds, flaxseed oil, avocado, chia seeds, hemp seeds, almonds, walnuts and walnut oil, olives and high-quality olive oil, basil seeds, and green leafy veggies. 
  • Foods Rich in EPA/DHA: Herring, salmon, sardines, oysters, trout, tuna, crab, eggs. 
• It is important to note that there is very inefficient conversion from ALA to EPA and DHA (only 8% of ALA converts to EPA and only up to 4% to DHA). For our patients, we typically recommend a combination of plant and animal sources of Omega 3 in the diet when possible. ⁴⁵ Algae omega 3 fatty acid supplement is another source of EPA and DHA for those who are vegan or are unable to tolerate fish oil.

CoQ10

• CoQ10 has been shown to improve both glucose and lipid metabolism, inflammation, and sex hormones in those with PCOS. ⁴⁶
• CoQ10 (at a dosing of 150mg daily for 4 months) may help to reduce oxidative stress and in turn support the function of the hypothalamic-pituitary-ovarian axis (HPA-O axis) and increase LH and FSH production. ⁴⁷
• For women using assisted reproductive technology:
  • There may also be benefits to the quality of the embryos when supplementing with high doses of CoQ10 (600mg/day for 2 months). This requires more research, however. ⁴⁸
  • Supplementation with CoQ10 may improve pregnancy outcomes when compared to a placebo. ⁴⁹

Soy Isoflavones

• Isoflavones are a type of phytoestrogen, which are compounds found in plants that have a structure that is similar to that of estrogen and as a result can interact with and bind to our estrogen receptors.
• Isoflavones are most commonly found in soy products such as tofu, edamame, tempeh as well as lentils, beans, and peas.
• Supplementation with isoflavones is also possible. In one study, women who supplemented with genistein (a type of isoflavone) for a three-month period, showed a reduction in luteinizing hormone, triglycerides, LDL, DHEAS and testosterone. ⁵⁰

ALA

• ALA (alpha lipoic acid) is a powerful antioxidant that supports healthy modulation of insulin sensitivity, improves glucose control and triglyceride levels and is even more effective when paired with myo-inositol. ⁵¹
• ALA can support hormonal balance and, in some instances, has been shown to reduce LH (luteinizing hormone). When paired with myo-inositol  it can reduce testosterone and DHEAS. ⁵²
• ALA can help with menstrual regularity as well as cycle length and when paired with myo-inositol has been show to have positive effects on oocyte quality. ⁵³

Akkermansia: for hyperglycemia and insulin resistance support

• Akkermansia is a mucin degrading bacterium that is commonly found in our gut.
• Low or undetectable levels of Akkermansia have been associated with obesity, diabetes, inflammation and metabolic disorders. ⁵⁴
• Studies have found that women with PCOS in general have a decreased level of Akkermansia. ⁵⁵
• Akkermansia is known for its support with hyperglycemia and insulin resistance. It can also increase GLP-1 (glucagon-like peptide 1) production which aids individuals in maintaining an optimal weight. 
• One study found that dietary polyphenols, specifically cranberry extract and grape polyphenols, can help to increase the abundance of Akkermansia in the gut. ⁵⁶
• Akkermansia can be taken as a probiotic empirically or when akkermansia levels are found to be low on the comprehensive stool test.

There are a wide variety of supplemental interventions to consider for those with PCOS. Please be sure to discuss the appropriate supplementation protocol and dosing for any of the supplements considered here. Please keep in mind that to see the most beneficial improvements in PCOS symptoms it is important to pair supplements with nutrition and lifestyle changes. In some situations, medications or medical interventions may be part of a robust plan for healing. To learn more about PCOS and the associated symptoms, find our blog here and to learn more about nutritional interventions for PCOS you can read our blog here.

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