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Labwork Suggestions for PCOS in Young Woman

(This is a sample entry from the SAFM Q&A Treasure Chest, a tool with hundreds of entries to support students with their client needs. Students get unlimited access as part of SAFM’s functional medicine training program.)

Student Question:

Hi Tracy,
I have a 19 year old patient who was diagnosed with PCOS when she was about 17. She has a history of weight fluctuations. She is 5’4″ and 158 lbs and would like to drop some weight. She is on Metformin 800mg/day as prescribed by her PCP. She is allergic to mold and takes Allegra everyday so that she can go to class. (Her classroom triggers her allergies – which is not a surprise! We discussed her addressing this issue with the college.)  She is aware of the link between PCOS and insulin resistance. She really wants to be proactive about her health. Our work will focus on keeping her blood sugar in check as well as finding ways to de-stress.   I would like current blood work, and she wishes to seek IgG testing for food sensitivities.  From a root cause perspective, what specific “everyday” labwork would you recommend?  Thanks!

SAFM Response:

It is indeed unfortunate that we so often see hormone imbalance in women this young!  As you said, PCOS is very often correlated with insulin resistance.  High insulin levels can promote the formation of higher testosterone in the ovaries which can cause a variety of symptoms, including anovulation which can result in low progesterone and thus generate an even more complex imbalance by creating estrogen dominance.  Keep in mind too that not all PCOS is driven by an insulin resistance dynamic; there are exceptions.  Be sure to consider the possibility of ovarian dysfunction as a result of exposure to xenoestrogenic chemicals and include a thorough education/inventory of exposure possibilities with your patient.  High stress can also promote higher androgen release from the adrenal glands as well.  There is dispute in the medical arena as to whether PCOS might also have genetic origins in some cases.

Here is a list of labwork that I think would be helpful in identifying helpful lifestyle choices to reduce typical PCOS symptoms and help this woman in particular:

  • Fasting Insulin.  Keep in mind that very early stages of insulin resistance may not result in higher fasting blood sugar or HbA1c, so checking insulin directly is an important baseline.
  • HbA1c.  To check the progression of insulin resistance into hyperglycemia.  Another important baseline as you work to reverse the insulin resistance.
  • Vitamin D and Vitamin A.  Both are key given allergy history.
  • RBC magnesium.  Insulin resistance promotes poor cellular magnesium and vice versa.  This can increase cramping and anxiety, two common symptoms in PCOS.
  • RBC Zinc.  Key for immune system regulation.
  • Total and Free Testosterone.  Ideally, a more comprehensive urinary hormone assessment is completed in order to understand the role of adrenal hormones and also overall sex hormone metabolism (she may have high levels of DHT without overall high free or total testosterone).  You could also check estrogen metabolism and clearance with this type of profile.  However, given the notion of “everyday”, broadly accessible labwork in your question, these two markers, however, can be readily measured in blood for ease to at least examine the extent to which higher levels of *this* androgen might be at play in her symptoms.  You could also check DHEA-S, another androgen.
  • Serum B12.  A common side effect of metformin is Vitamin B12 depletion.  And B12 is important for methylation which the body uses internally to break down histamine.
  • Full thyroid panel.  TSH, Free T4, Free T3, and both Tg and TPO thyroid auto-antibodies. Given her fluctuating weight, it is likely there is thyroid imbalance, and sex hormones have a large effect on metabolic hormone action as well.
  • Triglycerides.  To check for lipid impact of elevated blood sugar.  Optimal is <100.

I also want to say a few words about further antibody testing:

  • IgG food panel.  Of course, this is definitely not “everyday labwork”, but you mentioned it and I agree it may be of value in this case.  Persistent, high histamine secretion promotes intestinal permeability and damage to the protective mucosal lining of the intestines, so I agree that this is a prudent choice.  In my experience, many people with mold allergies will have strong food sensitivities to yeast.  Keep in mind that no type of food sensitivity test is fully comprehensive, and all are vulnerable to false positives and negatives.  If you are unfamiliar, I recommend you consider this post as well.  The Understanding Asthma and Allergy clinical course addresses this topic in detail.
  • IgE testing is also a possibility if she is suspicious there are other histamine-mediated allergies.

Assuming insulin resistance is confirmed, I recommend you reference the recommendations in the Reversing Metabolic Dysfunction clinical course as a key focus area.  I also would search here in the Q&A Treasure Chest for a post on “inositol” as a particularly powerful remedy for PCOS.

I know your question was focused on labwork suggestions, but I want to offer a few thoughts on initial recommendations you might choose.  If there is a confirmed insulin resistance element at work, I definitely recommend you focus on stress (as well as diet).   We know that elevated levels of stress hormones can also promote high blood sugar separate from (or exacerbated by) a high-glycemic diet.  As a starting point, for weight loss, I would highly recommend elimination of all dairy foods (given her allergies) and also all foods made with grain flours.  I know you will recommend a daily probiotic to help to calm her immune system (make sure it’s not one that promotes higher histamine secretion; I personally would choose Lactobacillus Plantarum or Rhamnosus e.g. Metagenics UltraFlora Intensive Care).  Omega-3s will be helpful in reducing triglycerides and increasing HDL.  Berberine is a particularly good alternative to metformin which does not cause Vitamin B12 depletion, or it may be used in combination, if necessary in the short-term.  Also, a B-complex (e.g. Thorne’s Basic B) is likely key to help with estrogen detoxification (many other posts you may search for on this topic too with other recommendations).   And perhaps a multi-herb formula to help reduce the histamine response (e.g. Designs for Health’s HistaEze) that includes quercetin and stinging nettle leaf.   And of course, getting away from the allergens is absolutely  key for long-term health and not developing more aggressive immune system reactions.  This will be a critical educational focus in your work with this patient.

P.S.  If you are passionate about transforming healthcare through the power of functional medicine, we encourage you to learn more about our training program here.

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Beth Finnigan

Would you apply this line of lab work and lifestyle considerations for a woman diagnosed with endometriosis? Particularly as blood sugar as a possible contributory factor?

SAFM Team
Reply to  Beth Finnigan

This is a very specific case discussion that focuses on the PCOS and allergies dynamic. That being said, yes, a lot of the lab work and lifestyle recommendations mentioned in this post could apply to a woman struggling with endometriosis and blood sugar issues. The case that you are describing calls for figuring out the actual causes of estrogen dominance (the primary driver for endometriosis), specifically if it is due to insufficient progesterone (estrogen is at normal levels but in excess in relation to the progesterone), or excess of estrogen due to issues with liver or gut clearance (detox issues), ongoing exposure to xenoestrogens or conversion of testosterone to estrogen (stress and sugar). Taking all this into consideration, all the blood sugar balance lab work will be helpful and also a comprehensive urinary hormone assessment to understand the role of overall sex hormone metabolism and adrenal hormones balance. Thyroid panel will be the next choice as excess estrogen can negatively affect thyroid function and that could be another contributing factor to insulin resistance. In addition to what you found here, please remember that it is also not uncommon for people eating a high glycemic and/or toxin-containing foods to develop gut… Read more »