PCOS Support

Guide
Patient Guide
Table of contents
What is PCOS? 04 Spice it up 14
Statistics
Eat cleanly 15
Signs and symptoms
Diagnosis
Specific nutrients to support women with PCOS 16
Vitamin D
Causes of PCOS 05
Omega-3 fatty acids
Conditions associated with PCOS 06 Inositol
Folate
Relationship between the microbiome and PCOS 07
Botanicals that can benefit women with PCOS 18
The inflammation connection 07 Curcumin
Bergamot
Why lifestyle approaches are so important 08
Berberine
Dietary advice 09
Exercise for PCOS 19
Mediterranean diet
Low glycemic index/load diet
Stress reduction 20
Ketogenic diet
Sleep 21
Other dietary considerations 12
Sugars Additional supportive resources 21
Fats
Recommendations for you 22
Protein
Fiber
Recipes 24
Mediterranean diet/low glycemic index
Keto diet

References 30
What is
Polycystic ovary syndrome (PCOS) is a common hormonal condition
that affects teenage girls and women of childbearing age. It is estimated
that it affects 6-12 percent of the U.S. female population, with a wider

PCOS?
range worldwide – 4-20 percent. One reason it is difficult to pinpoint the
prevalence of PCOS more accurately is that it is estimated that at least half
the girls and women who have PCOS don’t know they have it.

Although PCOS is normally diagnosed when a girl reaches puberty, it

Statistics, signs, might not be recognized until later, when a woman has unexplained weight
gain or difficulty becoming pregnant. PCOS can have an adverse impact
symptoms, and diagnosis on the overall health and appearance of a woman. Although menstrual
irregularities and infertility place the diagnostic and treatment focus on
women of childbearing age, PCOS can be a lifelong problem, affecting
both menopausal and postmenopausal women with metabolic issues, such
as cardiovascular disease and diabetes.

A diagnosis of PCOS requires at least

two of the following three signs or
symptoms:
⁄ Infrequent, irregular, or prolonged menstrual cycles. This can range from
fewer than nine periods a year to more than 35 days between periods to
abnormally heavy periods.

⁄ A high testosterone level that can manifest as excess facial and body hair
(hirsutism), acne (sometimes severe), and/or male-pattern baldness.

⁄ Ovarian cysts caused by the ovaries not forming eggs properly or not
releasing eggs during ovulation, causing fluid-filled sacs (the cysts),
which can lead to fertility problems.

Between 50-80 percent of PCOS patients are also overweight. Other less
common symptoms include darkening of the skin in the folds of the neck,
groin, or under the breasts, and skin tags in armpits or on the neck.

4
Causes of
There doesn’t appear to be one specific cause of PCOS; rather, there are
several contributing factors – and in some cases, it’s the old chicken or egg
conundrum – cause or effect?

PCOS Overweight. It is estimated that between 50-80 percent of women who

have PCOS are overweight or obese. Fat cells or adipocytes release a
variety of fatty acids, hormones, and inflammatory chemicals that can
interfere with insulin signaling and result in insulin resistance.

Insulin resistance. Insulin resistance (IR) is a common occurrence in

women who have PCOS, and it likely contributes to its development. IR
is the inability of insulin to do its job properly. Although the pancreas
secretes insulin, the insulin isn’t able to bind to receptors on cells and usher
sugar from the bloodstream into the cells. This results in the body secreting
more insulin to compensate – the result: increased insulin and blood sugar.

Hormone imbalance. Although testosterone is often thought of as a

male hormone, women also need smaller amounts of testosterone to
maintain good health. Insulin resistance can cause the ovaries to produce
too much testosterone, which can then interfere with the development
of ovarian follicles (the sacs where eggs develop) and prevent ovulation.
This in turn results in the characteristic ovarian cysts seen in PCOS.
Elevated testosterone also contributes to many other characteristic signs
of PCOS, such as male-pattern baldness, excess facial/body hair, and
acne. Other androgen hormones can be elevated too – such as DHEA, a
precursor to testosterone.

Inflammation. Chronic inflammation can contribute to PCOS, and

being overweight or obese contributes to general inflammation in the
body because fat cells secrete inflammatory chemicals called cytokines
(although one can have chronic inflammation, even if they aren’t
overweight). Like insulin resistance, too much inflammation can cause
the ovaries to produce testosterone. Some of the inflammatory markers
elevated in women with PCOS include C-reactive protein (CRP), tumor
necrosis factor-alpha (TNF-α), and interleukin (IL)-18 (see The Inflammation
Connection section).

Environment. Exposure to environmental pollutants can contribute

to increased PCOS risk. For example, women who have PCOS can
have higher blood levels of endocrine disruptors like bisphenol-A (BPA;
used in plastic manufacturing) than other women.1 Higher levels of
other environmental toxins have also been found in women with PCOS:
pesticides, fluorinated hydrocarbons (used in non-stick cookware, for
example), polybrominated diphenyl ethers and polybrominated biphenyls
(used in flame retardants), and polychlorinated biphenyls (PCBs) – potent
carcinogens that collects in fat tissue. Although PCB use in manufacturing
was banned in the United States in 1979 and worldwide in 2001 by the
Stockholm Convention, PCBs remain a significant environmental pollutant
because they can persist for longer than 100 years.2,3

Genetics. Genes likely play a part in a woman’s risk for developing PCOS. A
woman whose mother has PCOS is five times as likely to develop it herself.

Microbiome. Disordered vaginal and gut microbiomes can contribute to

PCOS (see Relationship between the Gut Microbiome and PCOS section).

5
Conditions
A woman who has PCOS is at higher risk for other health concerns – and,
in some cases, it’s difficult to determine whether the condition is a result of
or a cause of PCOS. Associated conditions include:

associated ⁄ Infertility. Women with PCOS have 15 times the risk of infertility than
women without PCOS. Although infertility is often the reason a woman

with PCOS
seeks medical advice, there are numerous other associated conditions.

⁄ Difficulty managing weight. Excess weight can be a cause or an effect

of PCOS. Sometimes PCOS symptoms don’t manifest until a woman
gains significant weight. On the other hand, women with PCOS tend to
gain weight easily. The extra weight can contribute to other health issues.

⁄ Metabolic syndrome. Many aspects of metabolic syndrome are also

seen in women with PCOS – including insulin resistance, obesity in some
cases, and elevated cholesterol.

⁄ Diabetes. Statistics indicate that approximately 30 percent of women

who have PCOS have impaired glucose tolerance, while an additional
eight percent have diabetes.

⁄ Inflammation. Evidence suggests low-grade inflammation causes the

ovaries to produce excess androgens (testosterone and its precursors).

⁄ Cardiovascular disease. Excess androgen hormones and being

overweight can increase the risk for chronic diseases of the heart and
blood vessels.

⁄ Sleep apnea. In one study, women who had PCOS were 30 times more
likely to suffer from disordered breathing when sleeping – sleep apnea –
than women who didn’t have PCOS.

⁄ Fatty liver. Numerous clinical studies point to the increased prevalence

of non-alcoholic fatty liver disease (NAFLD) in women who have PCOS,
independent of weight or other metabolic syndrome factors.

⁄ Eating disorders/disordered eating. Women who have PCOS are more

likely to experience food cravings, poor impulse control around eating,
and increased appetite. Eating disorders, particularly binge eating/
bulimia are also more common in women with PCOS.

⁄ Anxiety and depression. Women with PCOS report a higher prevalence

of depression, anxiety, and perceived stress than other women.1

6
Relationship
Sex hormones appear to impact both the gut and vaginal microbiomes.
For example, a healthy vaginal microbiome is comprised of numerous
species of Lactobacilli, which thrive when estrogen is prevalent.

between the
Women who have PCOS tend to have specific microbiome compositions.
Their vaginal microbiomes tend to be characterized by a low number of
Lactobacillus species and high amounts of pro-inflammatory microbiota,
which increases the risk of infection and the odds of adverse reproductive

microbiome issues, such as infertility and pregnancy loss. This microbial shift away from
beneficial Lactobacilli is likely due, at least in part, to hormone imbalances
of excess testosterone and other androgens in relation to estrogen.

and PCOS The gut microbiome in women with PCOS is characterized by reduced
species diversity and lower numbers of beneficial short-chain fatty acids
(SCFAs). Abundant SCFAs are linked to improved gut health, a healthy
immune system response, and reduced inflammation.

Thus, disordered vaginal and gut microbiomes can contribute to the overall
inflammatory load prevalent in PCOS.

The
Although fat accumulation and weight issues can significantly affect the
heart and blood vessels, fat cells increase systemic inflammation, which
can have adverse metabolic effects throughout the body. Although

inflammation
short-term (acute) inflammation is a good thing – usually the result of your
immune system mounting a reaction against an invading organism, irritant,
or allergen, or an injury – long-term inflammation is at the center of many
chronic conditions, including PCOS and associated conditions, such

connection as heart disease. It’s all a matter of balance. Click here for a short video
on the connection between chronic inflammation and heart disease (a
Thorne-Mayo Clinic collaboration).

Chronic low-level inflammation occurs first in the adipocytes, with an

increase in TNF-α.1 TNF-α stimulates a more general inflammatory state
that can ultimately result in insulin resistance and other signs of metabolic
dysfunction. In addition, a review that pooled the results of 63 clinical
studies found that women who had PCOS, regardless of weight status, had
higher levels of the inflammatory marker C-reactive protein than women
without PCOS.2

Therefore, diet, lifestyle, and nutritional supplementation approaches

should focus on measures to decrease inflammatory load.

7
Why
What does conventional medicine have to offer? There is no silver-
bullet cure for PCOS. Conventional medicine focuses on medications or
procedures that address specific aspects of PCOS – hormones, assisted

lifestyle
reproductive techniques, ovulation-stimulating drugs, and medications,
like metformin, that address metabolic issues. But none of these address
the whole woman, which is why many women turn to diet, lifestyle, and
nutritional supplement approaches.

approaches
are so
important

8
Dietary
Numerous diets have been studied for supporting women with PCOS –
including the Mediterranean and ketogenic diets. As little as 5-10 percent
loss of body weight can make a big difference in reducing PCOS symptoms

advice
and restoring ovulation. So, in addition to other health benefits, it is
important to find a diet that can help support your weight goals – whether
the goal is to lose weight or maintain a healthy weight. Let’s look at what
several of the eating plans have to offer a woman who has PCOS.

Mediterranean diet
For the sixth year in a row, the Mediterranean diet is ranked best overall
diet by U.S. News & World Report.1

Benefits. The Mediterranean diet (MedDiet) has been the most extensively
studied diet for benefitting various aspects of PCOS. Studies show
adherence to the MedDiet:2-4

⁄ Decreases the incidence or severity of PCOS

⁄ Improves insulin sensitivity

⁄ Decreases inflammation

⁄ Decreases oxidative stress

⁄ Improves body composition

⁄ Supports weight loss

⁄ Prevents metabolic syndrome

⁄ Improves ovarian structure and function

⁄ Decreases androgens

⁄ Improves the composition of the gut microbiome, which decreases

inflammation

Components. The Mediterranean diet consists of large amounts of

vegetables and moderate amounts of fruit, in addition to whole grains,
beans, nuts, and seeds. Fish, and to a lesser extent low-fat meat and
poultry, are eaten in moderation. Fresh fruit is the typical daily dessert
and olive oil is the primary source of fat. Red wine can be consumed in
moderation. Simple carbs are kept to a minimum.

9
Dietary
Although the Mediterranean diet is essentially an anti-inflammatory diet,
the Thorne Modified Mediterranean Diet goes a step further to ensure
you are not including common allergens in your diet that can contribute

advice
to inflammation. The most common foods that cause food allergies or
sensitivities are dairy, gluten (wheat, barley, rye), soy, eggs, fish, shellfish,
peanuts, tree nuts, and sesame.

The health benefits of the MedDiet are attributable to the high level
of plant polyphenols in vegetables, fruits, olive oil, and wine. Anti-
inflammatory effects of the omega-3s in fish and nuts also contribute to
the MedDiet’s health benefits.

What about vegans? A vegan can still obtain the benefits of the MedDiet.
It requires an emphasis on legumes – what has become popularized as the
“pulse diet” – to include a variety of beans, lentils, and peas. Quinoa and
soy products, such as tofu or tempeh, provide all essential amino acids,
meaning they are complete proteins. If these are not included, then eating
a wide variety of legumes, nuts, and seeds can fill this gap. Vegans might
also need nutritional supplements, particularly vitamin B12, vitamin D, and
omega-3 fatty acids – nutrients often lacking in a vegan diet.

Need to jumpstart weight loss? If a more restrictive diet is required –

to get a jumpstart on weight loss – then check out the Thorne Weight
Management Program guide that incorporates a lower-carb, lower-fat
version of the MedDiet. The Guide provides specific diet guidelines and is
designed to be used in 2-week increments.

Low glycemic index/load diet

Because PCOS is strongly associated with dysfunctional blood sugar
metabolism – insulin resistance in particular – a focus on lower glycemic
index (GI) foods is indicated. The MedDiet has the potential to also include
higher GI foods. Thus, if the MedDiet is your diet of choice, then focus on
foods with a low GI.

Benefits. Pooled data from analysis of eight studies comparing low- and
high-glycemic index diets in women who had PCOS found a low-GI diet:5

⁄ Decreased insulin resistance ⁄ Decreased LDL cholesterol

(measured by HOMA-IR)
⁄ Decreased triglycerides
⁄ Decreased fasting insulin
⁄ Decreased waist circumference
⁄ Decreased total cholesterol
⁄ Decreased testosterone

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Dietary
Components. What are low-glycemic index foods? A low-GI food is one
that results in a gradual rise in blood sugar when eaten – rather than a
spike. The glycemic index ranks carbohydrates on a scale of 0-100, based

advice
on the extent to which the carbohydrate in the food increases fasting
blood sugar in healthy people. The lower the glycemic index number, the
less the food’s impact on blood sugar. The glycemic load is based on the
glycemic index, but it also takes into account the amount of carbohydrate
in a specific serving. The recommended value of a food’s glycemic index is
55 or less and 10 or less for the glycemic load. Glycemicindex.com allows
you to type in a food and receive its glycemic index and glycemic load. Use
it as a general guide.

The glycemic Low GI (54 or less) Medium GI (55-69) High GI (70 or more)

index of some ⁄ Barley ⁄ Rice ⁄ White bread

common foods ⁄ Sweet potatoes ⁄ Most fruits ⁄ Processed foods
⁄ Most vegetables ⁄ Pasta ⁄ Soda
⁄ Yogurt ⁄ Oatmeal ⁄ Bagels

Ketogenic diet
Although not as extensively studied as the MedDiet, the ketogenic (keto)
diet has been studied in women with PCOS. By its very nature, it is a low-
glycemic index diet – so if it’s keto, then it’s low GI too.

Benefits. The keto diet can impact these aspects of PCOS:2

⁄ Decreases insulin resistance

⁄ Increases sex hormone-binding globulin (SHBG) – a protein that binds

testosterone, thus decreasing free testosterone

⁄ Reduces the ratio of luteinizing hormone (LH) to follicle-stimulating

hormone (FSH) (which tends to be high in PCOS and inhibits ovulation)

⁄ Supports weight loss

Components. The keto diet is heavily restrictive of carbohydrates,

moderate in dietary protein amounts, and high in dietary fat. The concept
is that this diet causes your body to switch from burning carbohydrates for
fuel to almost exclusively burning fat instead, and, when this occurs, your
body is in a state of nutritional ketosis.

Although the keto diet might have short-term benefits for PCOS, it might
not be the best long-term maintenance diet because it can be deficient
in fiber and some vitamins and minerals. In addition, most studies that
analyzed metabolic benefits for blood sugar, insulin resistance, weight loss,
cardiovascular health, and fatty liver looked at a very low-calorie keto diet,
while a basic keto diet does not restrict calories.6

11
Other dietary
In addition to all the good stuff to include in a PCOS diet, a discussion
would not be complete without some mention of major food groups – the
good and the bad.

considerations Sugars
Sugar/High-fructose corn syrup. One of the biggest culprits is high-
fructose corn syrup (HFCS) – which is used in soft drinks and in many
processed foods. Its increased use over the past several decades mirrors
the increase in obesity and associated metabolic derangements seen in
the Unites States. Although sugar of any kind should be kept to a minimum,
HFCS is implicated in PCOS-related health outcomes, including weight
gain/obesity, insulin resistance, fatty liver, increased triglycerides, leptin
resistance, increased protein glycosylation, and type 2 diabetes.1

Fats
Bad fats. Although fats are an essential component of a healthy diet, it is
important to draw a distinction between “good fats” and “bad fats.” Trans
fats – artificially prepared fats, also referred to as hydrogenated fats (made
by pumping hydrogen into the fat), found in margarine and other products
(check labels!) – have been implicated in metabolic impairment. Trans fats
were developed to convert liquid vegetable oils into solids, making them
spreadable and increasing their shelf life. When trans fats were developed,
butter was demonized as being artery clogging and bad for your heart. As
it turns out, trans fats are far worse.

Vegetable oils like safflower or corn oil are high in polyunsaturated

fatty acids (PUFAs) that can create inflammation by causing an
imbalance between omega-6 and omega-3 fatty acids. Heating these
polyunsaturated oils can also create cell-damaging free radicals.

Good fats. On the other hand, the omega-3 fatty acids EPA and DHA
found in fatty cold-water fish are beneficial. The benefits of cold-water
fish and their oils are due in part to their ability to help maintain a balanced
inflammatory response throughout the body.

And there is a reason the MedDiet ranks so high as an overall healthy

diet. As the primary oil in the MedDiet, olive oil is high in antioxidants and
monounsaturated fatty acids (MUFAs), which means when it is lightly
heated for cooking it does not produce free radicals like other vegetable
oils that are mostly polyunsaturated do. Free radicals are molecules that
disrupt cells and wreak havoc in the body. Organic, extra-virgin olive oil is
recommended and can be used cold in salads and other dishes or in light
sauteing. It is best not to cook with it on high heat because its essential
health-providing nutrients can be destroyed.

Avocado oil has a similar fat profile to olive oil – high in MUFAs and
antioxidants – and is a better choice than olive oil when high heat is
needed for cooking because it has a higher smoking point. This means you
can cook with avocado oil at a higher temperature before it starts tasting
bad and being bad for you and your kitchen.

12
Other dietary Protein
A study analyzing a 3-day diet diary from 54 women with PCOS found

considerations
that 36.7 percent of them had diets insufficient in protein.2 The sources of
protein in your diet will depend on whether you have chosen the keto diet
or the MedDiet. Lean meat, fish, and poultry can be consumed with either
diet, although the MedDiet focuses more heavily on fish and incorporates
legumes, which are also good sources of fiber and have a beneficial effect
on blood sugar – low glycemic index. Although the keto diet avoids most
legumes, there are a few low-carb choices, including soybeans and lupini
beans, which can be eaten in moderation. Lupini beans are also higher in
protein than many legumes – 13 grams per half cup of cooked beans.

Fiber
The same 3-day study found the women’s diets to be low in fiber, while
higher than desirable in saturated fat, cholesterol, and sugar. In its analysis,
83.3 percent of the participants reported low fiber intake – defined as less
than 25 grams of fiber daily. Eating a MedDiet is a good place to start in
terms of increasing fiber intake.2

If you are looking to add extra fiber, then flaxseed is a particularly good
choice. Flaxseed is known to lower testosterone levels because it binds
to testosterone and removes it from the body. In a case study of a woman
with a high testosterone level, 30 grams of flaxseed daily for four months
significantly decreased her total and free testosterone levels.3

13
Spice it up
You need not look further than your kitchen cabinet to find herbs and
spices that can help modulate some aspects of PCOS.

Spearmint tea was tested in 42 women with hirsutism, which is often

associated with an elevated level of testosterone or DHEA. For 30 days,
the women were randomized to drink either two cups of spearmint tea
daily or a placebo tea. Women in the spearmint tea group had significant
decreases in total and free testosterone levels compared to the women in
the placebo tea group.1

Cinnamon. A significant body of information points to the benefit of

cinnamon for supporting several cardiometabolic derangements associated
with PCOS. In a study of 60 men and women with type 2 diabetes, one-half
teaspoon of cinnamon daily for 40 days resulted in decreases in fasting blood
sugar, triglycerides, LDL cholesterol, and total cholesterol.2 Another large
review study that analyzed the effects of 10 double-blind clinical studies
found similar positive effects on cholesterol, triglycerides, and fasting blood
sugar.3 Cinnamon has also been shown to lower blood pressure.4

Turmeric. Turmeric has numerous antioxidant constituents that are not

sensitive to destruction by cooking. Several studies have looked at the
effect of turmeric on metabolic risk factors associated with PCOS. One
study found 2.4 grams (approximately 1 ¼ teaspoons) of turmeric daily for
Effect of spices on metabolic four weeks resulted in reduced LDL cholesterol and C-reactive protein.5

factors associated with PCOS Several other spices offer benefits for various aspect of PCOS.

Spice Health benefits Therapeutic amount

Decreases craving for junk food 1/8 teaspoon up to 1 ½ teaspoons

pepper-hot Cayenne pepper Increases fat burning; decreases body fat ½ teaspoon

Decreases LDL and increases HDL cholesterol Frequent dietary consumption

Cinnamon Decreases blood sugar, triglycerides, LDL and total cholesterol ½ teaspoon

Lowers blood pressure 600-900 mg (¼ -½ teaspoon) garlic powder

garlic Garlic
Lowers total and LDL cholesterol 2-4 cloves (20 grams)

Lowers triglycerides and total cholesterol Best results with less than 1 teaspoon daily

Ginger Lowers fasting blood sugar and HbA1c 1 teaspoon (2 grams)

Decreases inflammatory CRP Various amounts

Turmeric Decreases LDL cholesterol and CRP 1 ¼ teaspoons

Additional references available at the end

of this blog at Take 5 Daily: 5 Spices for a
Healthy Heart

14
Eat cleanly
PCOS is a condition associated with hormone imbalance. Therefore, meat
and poultry, eaten in moderation, should be free of endocrine-disrupting
hormones and organic when possible. Fish should be small, non-
accumulating, low-mercury fish. Some of the fish lowest in contaminants,
including PCBs and mercury, include trout, shrimp, halibut, flounder, tilapia,
cod, and haddock.

In addition, some studies have found increased levels of pesticides in

women who have PCOS.1 Therefore, produce should be organic when
possible – particularly the fruits and vegetables on the list of produce that
typically contain the highest amount of pesticide residues (referred to the
Dirty Dozen). The Environmental Working Group (EWG) tests produce each
year, and while the lists remain roughly the same from year to year, there
can be minor changes (the 2023 Dirty Dozen list is identical to the 2021
list).2 On the bright side, this EWG also comes up with a list of fruits and
vegetables least likely to contain pesticide residues – dubbed the Clean
Fifteen. If your favorite fruits and vegetables are not on either list, then it’s
likely they fall somewhere in between the cleanest 15 and the dirtiest 12; for
example, broccoli is #22. You can view the entire list of 46 tested fruits and
vegetables, going from dirtiest to cleanest, here: Environmental Working
Group's 2023 Shopper’s Guide to Pesticides in Produce.

As noted above, exposure to BPA increases the risk for PCOS. BPA can
leach into food from polycarbonate tableware, food storage containers,
the inner lining of canned foods (although many tin can manufacturers are
now using alternatives), and plastic water bottles.

2023 Dirty Dozen 2023 Clean Fifteen

strawberry apple-whole avocado potato

⁄ Strawberries ⁄ Apples ⁄ Avocados ⁄ Asparagus ⁄ Sweet
potatoes
leaf grapes corn melon
⁄ Spinach ⁄ Grapes ⁄ Sweet corn ⁄ Honeydew
watermelon-slice
melon ⁄ Watermelon
leafy-green pepper pineapple
⁄ Kale; collard and ⁄ Bell and hot ⁄ Pineapple
kiwi-fruit carrot
mustard greens peppers ⁄ Kiwi ⁄ Carrots
onion
⁄ Onions
peach cherries leafy-green
⁄ Peaches ⁄ Cherries ⁄ Cabbage
mango
⁄ Papaya
pear blueberries mushroom
⁄ Pears ⁄ Blueberries ⁄ Mushrooms
peapod
⁄ Sweet peas
peach mango
⁄ Nectarines ⁄ Green Beans (frozen) ⁄ Mangoes

15
Specific
In addition to macro-nutrient imbalances, the diets of women with PCOS
might be deficient in several specific vitamins and minerals. A study that
analyzed the diet diaries of women with PCOS found 70 percent had a

nutrients
low intake of folate, 36.7 percent had a low intake of vitamin C, and 26.7
percent had a low intake of vitamin B12. Intakes of calcium, potassium, and
magnesium were also below recommended daily amounts.1 In addition to a
healthy diet, women who have PCOS should be advised to incorporate a

for support multi-vitamin/mineral supplement into their daily regimen.

of women Vitamin D
Women with PCOS, particularly if they contend with a weight issue, tend to

with PCOS have a low vitamin D level. In a study that analyzed the diets of women with
PCOS, the average daily consumption of vitamin D was only 136 IU (Note:
The Recommended Daily Allowance for vitamin D is 600 IU, which is not
enough to maintain a sufficient level in many individuals).1

In one study, a low vitamin D level was associated with insulin resistance in
women with PCOS but not in a healthy control group.2 Evidence suggests
that maintaining a sufficient level of vitamin D supports a healthy balance
of testosterone and SHBG (the protein that binds to free testosterone),
benefits menstrual regularity, and decreases hirsutism.*

There are food sources of vitamin D, either naturally occurring or in foods

that have been fortified with it (see table). By far the food with the highest
amount of vitamin D3 is wild-caught salmon, which can have almost 1,000
IU in 3.5 ounces (100 grams). But because there are not many foods that
naturally contain vitamin D, it can be difficult to acquire the daily vitamin D
you require from diet alone, so a vitamin D supplement might be needed to
maintain an adequate level.

Foods naturally high in vitamin D3: Food often fortified with vitamin D (but read the label):

fish glass peapod

⁄ Fatty fish, including salmon, tuna, ⁄ Milk ⁄ Soy milk
mackerel, sardines, herring, halibut, trout
citrus-slice bowl-spoon
⁄ Orange juice ⁄ Cereals
steak egg
⁄ Beef liver ⁄ Eggs

bottle-droplet mushroom
⁄ Cod liver oil ⁄ Mushrooms
(vitamin D2)
cheese-swiss
⁄ Cheese

*These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.
16
Specific Omega-3 fatty acids
Besides being a good source of vitamin D, fish are high in omega-3 fatty

nutrients
acids. These important fatty acids offer nutritional support to women
with PCOS by supporting a normal inflammatory balance, a healthy
testosterone level, menstrual regularity, and a positive mood.*3,4

for support Fish that are high in omega-3s include salmon, mackerel, herring, sardines,
anchovies, lake trout, and albacore tuna (some of the same fish that
provide good dietary sources of vitamin D3). Addition of a nutritional

of women
supplement that contains both EPA and DHA (which are tested for the
presence of heavy metals and PCBs) would assure regular daily intake of
these important essential fatty acids without concern for contamination.

with PCOS
Inositol
Inositol is a naturally occurring substance in the body – found in high
concentrations in a number of tissues, including the brain. Inositol is
important for facilitating signals between cells in response to hormones,
neurotransmitters, and other important molecules. The combination of
myo-inositol and D-chiro-inositol provides nutritional support for women
who have PCOS by supporting insulin sensitivity.* This in turn supports
ovulation, menstrual regularity, healthy blood sugar maintenance,
androgen hormone balance, weight management, normal hair growth
(decreased hirsutism), and clear, non-oily skin.*5

Folate
As noted above, according to one study, 70 percent of women with PCOS
have insufficient dietary intake of folate, found in especially high amounts
in green leafy vegetables (folate got its name from the Latin word folium –
from which foliage was derived). Folate is essential when a woman is trying
to conceive. It is particularly important to have a sufficient folate level prior
to conception. Not only does folate help prevent neural tube birth defects
during the first trimester of fetal development, evidence also suggests a
higher folate level improves the likelihood of becoming pregnant.*

In one study, the women with the highest levels of folate had more
than a one-and-a-half times greater likelihood of becoming pregnant
compared to women with the lowest folate levels.*6 Another study
found women who reported taking folic acid alone or in a multivitamin
supplement had higher rates of pregnancy than women who did not take
folic acid.* Supplementation increased pregnancy rates by 10 percent in
women with a regular menstrual cycle and by 36 percent in women with
an irregular cycle.*7

Two other studies found that adding folate to myo-inositol might provide
even more benefit for supporting healthy oocytes (eggs), ovulation,
hormone balance, and pregnancy rate.*8,9

*These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.
17
Botanicals
Although there is a laundry list of botanicals that can provide benefit for
PCOS, here are a few standouts on the list (see also kitchen cabinet spices
in Spice It Up).

that can Curcumin

Curcumin is the primary curcuminoid found in the spice turmeric (Latin

benefit PCOS name Curcuma longa). Although turmeric has long been used as a spice in
Indian cooking and is what gives curry its golden color, both turmeric and
curcumin isolated from turmeric also have a long history of medicinal use.

An analysis of 12 studies found extracts of curcumin support healthy body

composition, including BMI, waist circumference, and body weight.*1

Like many flavonoids, curcumin is not well absorbed, but its absorption can
be improved when the botanical extract is bound to phospholipids to form
a phytosome. Curcumin phytosome has been studied for several metabolic
issues related to PCOS. It has been shown to support insulin sensitivity, as well
as maintenance of normal blood sugar, cholesterol, and triglyceride levels.*2,3
Curcumin has also been shown to support fat metabolism in the liver.*4

Bergamot
The yellow-green bergamot fruit, the size of a small orange, is a hybrid of
bitter orange and lemon. You might be most familiar with bergamot as an
ingredient in Earl Grey tea. The essential oil from the inner peel is mixed
with tea leaves, providing Earl Grey tea’s unique floral, citrus aroma and
flavor. Both the essential oils in the peel, as well as the polyphenols in the
juice, are used therapeutically, with the polyphenol fractions sparking the
most interest for metabolic health.

Two recent studies found bergamot polyphenols are superior to placebo

for their effects on fat metabolism, which in turn supports healthy
cholesterol and triglyceride levels.*5,6 Additional studies show similar
results in maintaining healthy lipid and blood sugar levels.*7-9

In addition to supporting healthy cholesterol and blood sugar levels,

bergamot can benefit individuals working on weight management.* Extracts
have been shown to support a decrease in visceral fat (the kind of fat stored
around organs) by supporting efficient fat metabolism.*5 Bergamot has also
been shown in clinical trials to promote healthy liver function, clearance of
fat from the liver, and a normal balance of liver enzymes.*9

Berberine
Berberine is a constituent of many plants, including Indian barberry,
Oregon grape, goldthread (Coptis), and goldenseal. Although berberine
has many potential therapeutic benefits, some of the best-researched
ones involve support for metabolic aspects of PCOS. In one study of
women with PCOS, berberine HCl (500 mg twice daily) significantly
improved BMI, waist circumference, and waist-to-hip ratio.* It also
significantly benefited glucose and lipid metabolism and supported
balanced testosterone and SHBG.*10

Other studies in women with PCOS found berberine promotes balanced

androgen levels, normal inflammatory responses, and insulin sensitivity.*11,12

*These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.
18
Exercise for
Research on PCOS and exercise points to the most significant benefits
coming from vigorous exercise, either alone or in combination with
resistance training. An analysis of 19 separate studies that included 777

PCOS
women with PCOS found that vigorous exercise was more important than
the length of time exercised in improving aspects of PCOS – specifically
BMI, waist circumference, insulin resistance, and cardiorespiratory fitness
(VO2peak). Taken together, the meta-analysis points to the most benefit
coming from exercising at least 120 minutes weekly for at least 10-12 weeks.1

Another systematic review found that vigorous aerobic exercise (at least
30 minutes three times weekly) was associated with improved insulin
resistance, while resistance/strength training was associated with
improved androgen levels.2

A third comprehensive review looked at high-intensity interval training

(HIIT) for impacting metabolic markers in women with PCOS. Seven trials
including 423 women found that HIIT three times weekly for 10 weeks
resulted in decreased BMI and HOMA-IR in PCOS.3

Summary of exercise recommendations:

⁄ Vigorous HIIT three times a week, for a total of 90-120 minutes weekly

⁄ Re-evaluate after a minimum of 10 weeks

⁄ Include resistance training twice weekly

According to this blog at Take 5 Daily in collaboration with Mayo Clinic,

HIIT might also slow the aging process. This specific form of exercise may
slow aging.

19
Stress
In addition to exercise, other stress-reducing techniques offer benefit to
women with PCOS.

reduction Mindfulness combined with yoga

Both mindfulness techniques and yoga might provide benefit. In one study,
31 women with PCOS were randomly assigned to a mindfulness yoga
group, while the other half had no intervention. Mindfulness training prior
to group mindfulness yoga sessions consisted of a three-hour tutorial on
breathing techniques, tapping, guided imagery, and positive self-talk. Yoga
sessions were one hour, three times weekly, for three months. In addition to
improvement in anxiety and depression, free testosterone was significantly
lower in the women who engaged in the yoga intervention, with DHEA
levels trending lower. Improvements in androgen levels were seen for as
long as three months after the intervention ended.1

Mindfulness meditation
In another study, 38 women with PCOS were randomly assigned to
mindfulness meditation or no intervention. Quality of life, anxiety, and
depression were assessed via questionnaires, and salivary cortisol was
measured at three time points during the day prior to the beginning of
the study and after eight weeks. The intervention group had a 30-minute
mindfulness tutorial and then practiced what they learned via a CD for
30 minutes daily – the recommendation was to do it at bedtime. The
women in the mindfulness group, but not in the control group, experienced
decreased anxiety, depression, and cortisol levels, as well as improved
quality of life.2

20
Sleep
As with so many other chronic health conditions, poor sleep is also
associated with PCOS. High levels of anxiety and depression in women
with PCOS are often seen in conjunction with sleep disorders. Poor sleep
is also associated with the metabolic disorders seen in PCOS, including
insulin resistance, overweight, activation of inflammatory pathways, and
type 2 diabetes. Although melatonin is thought of as a sleep hormone
secreted by the pineal gland in the brain, it is also found in many other
tissues in the body, including ovarian follicular fluid, where it provides
protective antioxidant effects. Melatonin levels have been noted to
decrease in follicular fluid of women with PCOS.1

What can you do? In addition to exercising and other stress reduction
techniques discussed here, avoid exposure to blue light at night. An
increasing amount of research is revealing that exposure to blue light – the
kind that comes from your cell phone, computer, tablet, or TV – can wreak
havoc with your sleep, particularly in the evening. So begin winding down
your exposure to blue-light emitting electronics a couple of hours before
going to bed. Studies show that for every hour you are exposed to blue
light, melatonin production is suppressed for half an hour. If you need to
use a blue-light emitting device before bed, then there are apps to reduce
blue light from screens or blue-light blocking glasses.

It is important to expose yourself to light – but in the morning, not in the

evening. If you can, sunlight is best. Weather and latitude permitting,
try getting 20-30 minutes of sunlight exposure in the morning. If your
schedule is tight, then combine it with exercise or meditation.

Create a bedtime ritual

⁄ Develop a bedtime ritual that works for you ⁄ Create a cool, dark, quiet sleeping environment

⁄ Take a warm (but not too hot) bath (add Epsom salts or lavender oil)
⁄ Noise should be limited to something soothing, like pink noise. There is
⁄ Have a relaxing cup of herbal tea, such as chamomile or emerging evidence that listening to certain sound frequencies – known
spearmint (see Spice it up section for added benefit of as pink noise – can enhance the deep phases of sleep. Pink noise is
spearmint tea) often found in nature, such as a steady rainfall. You can find recordings
of pink noise online here, for example. Look for a site that provides just
⁄ Keep on a schedule of going to bed and getting up the same time the sound with a black screen.
every day – even on weekends.

Additional supportive resources at

Take 5 Daily
Lifestyle Tips for Managing PCOS

The Most Frequent Cause of Female Infertility? PCOS

A Balancing Act: The Microbiome and Polycystic Ovary Syndrome

For additional help with fertility, see the Thorne Fertility Guide.

21
Recommendations for you
(This page is for your heath-care professional to make recommendations.)

Dietary recommendations

Follow the Mediterranean diet Follow the ketogenic diet

Follow the Mediterranean diet with low glycemic index Jumpstart with a low-fat, low-carb weight management diet for
weeks. (See Thorne Weight Management Program guide,
Follow the Thorne modified Mediterranean diet that eliminates which is set up in 2-week increments).
foods you are sensitive or allergic to

Other dietary recommendations

Supplement recommendations
Check the box(s) for the supplement recommendations.

Ovarian Care: scoops, per day Vitamin D-5000: capsule(s), per day

Metabolic Health: capsules, per day Super EPA: softgel(s), per day

MediBolic: scoop(s), per day 5-MTHF 5 mg: capsule(s), per day

(the Weight Management Guide protocol
recommends ½ scoop twice daily) Basic Prenatal: capsules, per day

Berberine: capsule(s), per day Prenatal DHA: softgels, per day

Women’s Daily Probiotic: capsule(s), per day

22
Recommendations for you
(This page is for your heath-care professional to make recommendations.)

Additional supplement recommendations

Exercise, stress, and sleep support recommendations

23
Recipes Mediterranean diet/low glycemic index recipes
Here are several recipes that are representative of the diet of populations living in the countries that
surround the Mediterranean Sea – including two vegan options – plus, they’re gluten free. These
three recipes are also suitable for a low-glycemic index diet. They are selected from the book,
Nourishing Meals: Healthy, Gluten-free Recipes for the Whole Family, by Alissa Sergersten and Tom
Malterre, MSN, CN.

Italian white bean soup

Serves: 12

Ingredients
2-3 tbsp Extra virgin olive oil 1 tsp Ground black pepper
12 cups Chicken stock 2-3 cups Thinly sliced kale
1 large Onion, chopped 2 tbsp Italian seasoning
4 cups Diced tomatoes 1/2-1 cup Chopped parsley
3-4 cloves Garlic, crushed 4-5 Carrots, diced
3-4 tbsp Tomato paste 3 tsp Herbamare or sea salt
1 tsp Paprika 3-4 stalks Celery, chopped
6 cups Cooked navy beans 1/2 lb Green beans, cut into 2-inch pieces

Directions
Heat an 8-quart pot over medium heat and add olive oil, then add onion; sauté for 8-10 minutes or
until soft and beginning to change color.

Add garlic, spices, and herbs; sauté one minute more. Then add carrots, celery, and green beans;
sauté for 2 minutes. Then add stock, tomatoes, and tomato paste, and cover and simmer for 20-25
minutes or until the vegetables are tender.

Stir in cooked beans, kale, and parsley; simmer 5 minutes more. Add salt; taste and adjust salt and
seasonings if necessary. Store leftovers in the refrigerator for up to a week.

24
Recipes Slow cooker chicken stew
Serves: 4-6

Serve this stew over cooked long-grain brown rice with a salad on the side. Using a slow cooker the
flavors come together beautifully and the chicken is very tender.

Ingredients 14 oz Canned crushed fire-roasted tomatoes

1 cup Diced shallots 1 cup Water

3 stalks Celery, diced 1/3 cup Dry white wine

4 Carrots, peeled and diced 1/4 cup Extra virgin olive oil

1.5 lbs Boneless chicken breast, 1 tbsp Italian seasoning

cut into chunks 1-2 tsp Herbamare or sea salt
Etc Ground black pepper

Directions
Add all ingredients to a slow cooker and cook on high for 4-5 hours or on low for 6-8 hours.

Oven Variation: Place all ingredients in a covered casserole dish and bake for 2.5 hours
at 300°F.

25
Recipes Chipotle black bean & yam stew
Serves: 6-8

When using canned black beans it will take about four cans. Be sure to save the bean cooking liquid
from the cans. Bean cooking liquid rather than water works better in this recipe to create a thicker
stew. You can also substitute the yams in this recipe with a small butternut squash that has been
peeled and diced.

Ingredients
2 tbsp Extra virgin olive oil 1/2 tsp Dried oregano
6 cups Cooked black beans 1 Lime, juiced (2-3 tbsp)
1 medium Yellow onion, chopped 1/2-1 tsp Chipotle chili powder
4 cups Bean cooking liquid or water 4 Cloves garlic, crushed
2 tsp Ground cumin 2-3 tsp Herbamare® or sea salt
1 medium Red bell pepper, diced 2 medium Yams, peeled & diced (~4 cups)

Directions
Heat a 6- or 8-quart pot over medium heat. Add the oil, then add onions; sauté for 5-7 minutes. Then
add the spices, Herbamare, yams, and garlic, and sauté a few minutes more.

Add the black beans and bean cooking liquid; simmer uncovered for 10-15 minutes or until yams are
barely tender but not yet cooked (timing will depend on the size of the diced yams). Add diced
peppers and simmer for 10 minutes more.

Taste and adjust salt and spices if necessary. Remove from heat and stir in lime juice.

Nutrition Tip: More and more research points to the importance of consuming foods that make your
intestinal microbiome happy. Researchers in Mexico have found that black beans do a great job at this. Black
beans contain a higher quantity of fiber that is not digestible by our enzymes, but are digested by organisms
in our intestines. These undigested black bean portions feed certain beneficial bacteria and allow them to
produce a substance called butyric acid, which is one of the preferred sources of energy for the cells lining
the colon, allowing them to function properly and remain healthy.

This blog on thorne.com – Take 5 Daily –

includes nine additional Mediterranean
diet recipes.
9 must-try breakfast, lunch, and dinner recipes for a Mediterranean diet.

And check out our Metabolic Syndrome Guide for additional recipes and
daily meal plans. You’ll even find some dessert recipes.

26
Keto diet
If you decide the ketogenic diet is the best option for you, then we have you covered there, too. This
first recipe might surprise you because it includes fruit, which is usually not acceptable in a keto
diet. Although most fruits are too high in carbs, berries are an exception – particularly raspberries,

recipes
strawberries, and blackberries. They are lower in carbs and higher in fiber than other fruits.

Berry blast yogurt parfait

Ingredients
Yogurt Base Fruit Addition and Nut addition

½ cup Unsweetened coconut yogurt (for ¼ cup Mixed berries, such as raspberries,
example, So Delicious brand = strawberries, and/or blackberries
5 grams of carbs) ¼ cup Spiced Low-Carb Pecans (see recipe
To taste Drops of liquid vanilla stevia (if this is below), chopped
your first time utilizing a sweetener
like stevia, then be mindful because
stevia is very sweet; so, start low
and work your up until you find your
desired sweetness level.)

Directions
Mix ingredients for the yogurt base. Start light on the liquid sweetener because you can always add
more, but hard to fix if it’s too sweet.

Fold the fruit addition into the yogurt base.

Sprinkle the chopped pecans over the fruit/yogurt mixture.

Enjoy!

Variation: Sprinkle powdered cinnamon or grate some lemon zest and add it to
the top of the mixture to bring about some different flavors.

27
Keto diet Spiced low-carb pecans
Ingredients

recipes
1 cup Raw pecan halves ¼ tsp Pumpkin pie spice
1/8 cup Butter, or vegan butter ¼ tsp Vanilla powder
1 tbsp Monk fruit in the raw ¼ tsp Salt

Directions
Preheat oven to bake at 325°F.

While the oven heats, melt the butter gently on the stovetop or in the microwave.

Add the dry ingredients to the melted butter and mix thoroughly with a fork to break up clumps.

Place the pecans onto a small baking sheet and cover them with the mixture. Roll the pecans in the
mixture to ensure even coating.

Bake the pecans for 10-12 minutes. Place the mixture on a piece of parchment to cool.

Variation: Want some heat? Sprinkle a pinch of cayenne on the pecans as

they cool to create some heat!

Keto stuffed peppers

from thebigmansworld.com

Serves 4

Ingredients
4 large Bell peppers 2 tbsp Keto taco seasoning
1 tbsp Olive oil (see recipe below)

1 small Onion finely chopped 1 15 oz Can of diced tomatoes in their juice

1 pound Lean ground beef (use ground turkey 1 cup Cauliflower rice steamed
or chicken if you prefer 2 cups Shredded cheese divided

Directions
Preheat the oven to 375°F. Lightly grease a large baking dish.

Slice off the tops of the bell peppers and remove seeds and excess membranes. Slice each bell
pepper in half and place them in the lined dish.

In a large non-stick pan, heat the olive oil on medium. When hot, add the onions and sauté for
one minute.

Add the ground meat and cook until no longer pink. Add the taco seasoning, then pour in the diced
tomatoes along with the juice. Let simmer for one minute.

Remove the pan from the heat. Stir in the steamed cauliflower rice and one cup of shredded cheese.

Evenly distribute the filling amongst the bell pepper halves and top with remaining cheese.

Bake the stuffed peppers for 20-25 minutes, until the cheese is melted and the bell peppers are tender.

Remove the stuffed peppers from the oven and serve immediately.

Note: If you prefer, then these can be cooked in an air fryer at 400°F for 10
28 minutes (turn after 5 minutes)
Keto diet Keto taco seasoning
from gimmedelicious.com

recipes
Ingredients
2 tbsp Chili powder 1 tsp Garlic powder
1 tbsp Cumin 1 tsp Onion powder
2 tsp Paprika 1 tsp Black pepper
2 tsp Salt 1 tsp Oregano

Directions
Add all spices to a mason jar, close tightly, and shake until mixed thoroughly

Check out more keto-friendly

recipes at Take 5 Daily:
8 Easy Keto-Friendly Recipes for Everyday Meals

29
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Eat cleanly
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