The PCOS gut connection is a surprising new approach to a complex condition that 1 in 10 women experience. Despite these large numbers, the medical model has little to offer beyond prescription medications – which can help but aren’t ‘answers.’ Part of the problem is a gaping hole in research when it comes to conditions that affect women, that have anything to do with gynecology specifically, or where there’s not one set of lab tests that prove you have a condition – as with PCOS.
For many women, it can take years to get a proper diagnosis (which it should not), despite dealing with a whole host of challenging symptoms. When it’s finally confirmed, most women are given very little direction and no treatment options beyond the Pill, Metformin, and Spironolactone, and other pharmaceuticals that may help in the short run, but don’t get under the hood to the root causes. But this is important to do (even if you’re also taking medications) because those root causes can drive other conditions, too, and it’s rarely optimal to manage a health condition solely with medications, indefinitely.
One significant root cause that research is revealing is the connection between the microbiome and PCOS. In fact, gut health may play a much bigger role in PCOS than was ever previously considered. Addressing gut health is an approach I consider important enough to include in most protocols for women with PCOS in my medical practice, and may help you find a safe, novel, and non-pharmaceutical approach to healing your PCOS, or one that adjunctively supports your health even if you are using pharmaceuticals as part of your PCOS healing plan.
PCOS: What’s Really Going on Under the Hood
Although there remains uncertainty as to what causes PCOS, we do know for certain that it’s far more complex than ‘just’ a gynecologic problem. There are three consistent patterns that are almost universal in women with PCOS: some amount of insulin resistance (metabolic dysfunction), elevated androgens (i.e. testosterone) and chronic inflammation.
Insulin resistance: This is when your cells stop responding sensitively to insulin in your bloodstream. This can lead to high blood sugar and put you at risk for other endocrine and metabolic-related issues like type 2 diabetes. It’s a key driver of inflammation, and a key driver of elevated androgens which we’ll talk about in a minute. As many as 70% of women with PCOS show significant insulin resistance – even if they’re at a “normal” weight. Insulin also causes us to store body fat, which is why many women with PCOS find it so difficult to lose weight. PCOS is also associated with an increased risk of binge eating (which I'll explain soon) and in turn, can lead to increased intake of high sugar and high carb foods that add to the blood sugar/insulin issues.
Elevated androgens (i.e. testosterone): If you have PCOS you might experience symptoms like frustrating weight loss resistance, distressing hair loss, hair growing in unwanted places (like your chin, breasts, or lower belly, for example) and cystic acne. These are all due to elevated androgen levels, which also interfere with ovulation, cycle regularity, and fertility. Interestingly, insulin resistance and elevated blood sugar drive increased androgen production, and in a vicious cycle, increased androgens further drive elevated blood sugar and insulin resistance.
Chronic inflammation: PCOS is considered a chronic inflammatory condition, meaning your body experiences persistent elevated levels of inflammation. Over time, this can damage tissues and put you at risk for a wide range of health conditions – anything from diabetes and heart disease to allergy and asthma. It’s suspected that chronic inflammation may also play a role in the anxiety and depression that are common symptoms of PCOS.
What’s Your Gut Got to Do With It?
So what’s your gut got to do with it? Your gut is home to trillions of microorganisms – bacteria, yeasts, and fungi, that play a central and essential role in regulating metabolism (blood sugar and insulin), nutritional status, hormone balance, appetite, and inflammation. Simply put, a healthy microbiome is one in which there is a high level of microbial diversity, and a preponderance of ‘the good bugs’ with a minimum of ‘bad bugs’ so that the microbiome can perform all of its important functions while you stay happy, healthy, and relatively symptom free.
Most of us living in this modern world actually have some level of hidden gut dysbiosis – imbalances in the types, diversity, and ratios of the microorganisms living in our gut, as a result of years or decades of antibiotic overuse, a standard western diet practically devoid of healthy fibers, diets high in sugar, stress, and even endocrine disrupting chemicals that have been found, beyond a shadow of a doubt, to unfavorably alter our intestinal ecosystems. In fact, it only takes about 3 days of eating a typical western diet to knock out whole species of good gut bugs, and feed the growth of the kind that we know are contributing to many of the chronic conditions that ail us – especially conditions like metabolic syndrome and diabetes, which now affect at least a third of the population, and which are thought to be largely due to diet and lifestyle, not solely genetics.
Microbiome health also requires a healthy gut lining, which when irritated, inflamed, or damaged, can alter the microbiome, but also lead to a problem called intestinal hyperpermeability, or more commonly, ‘leaky gut.” Leaky gut and microbiome disruptions go hand in hand much like the symbiotic relationship between healthy garden soil and healthy garden plants.
The relationship between the microbiome and leaky gut, to various metabolic diseases, hormonal, and inflammatory conditions has been well-established in the scientific literature, with profound connections to insulin resistance and diabetes, estrogen-related breast and other gynecologic cancers, and to autoimmune diseases.
That PCOS is both a metabolic and endocrine condition has led researchers to explore the gut-PCOS connection. This has led to findings that, I believe, validate the importance of taking an integrative approach to treating PCOS, beyond just medications – or perhaps as a true first-line approach prior to starting medications in many cases. Unfortunately, very little time is devoted to teaching physicians about PCOS, let alone about the microbiome or other aspects of gut health.
The PCOS Gut Connection
Multiple studies have shown that women with PCOS have significantly lower microbial diversity and an altered composition of microbes – favoring the unhealthy types of gut microorganisms over beneficial ones – compared to women without PCOS. One recent study, looking at the gut microbiome of teenagers with PCOS also found that these gut disruptions are present early on in the progression of this condition. Studies have also shown increased markers of leaky gut as well as general inflammation, in women with PCOS.
Growing research now also shows that dysbiosis and leaky gut play a significant role in the underlying factors that drive PCOS and its associated complications by influencing the key features noted above: insulin resistance, high androgen levels, and chronic inflammation. So much so that gut imbalances may not just be a significant contributing factor – but the cause.
Interestingly, since oral contraceptives are often a first-line medical recommendation for PCOS, I just want to mention that oral estrogen can contribute to leaky gut and studies have shown that it modifies the gut microbiome as well. There is also evidence that it can contribute to insulin resistance directly. If you are currently taking or have recently discontinued an estrogen-containing form of the Pill or any estrogen-based hormonal medications, it’s a good idea to pay extra attention to the health of your gut microbiome. You can do a low progestin-only Pill instead (ask your medical provider to prescribe one that doesn’t convert easily to androgens as that can worsen acne and hair loss with PCOS).
Here’s a brief overview of the gut-PCOS connection:
Women with PCOS have been found to have, as it’s described in the medical literature, a ‘defective insulin response.’ Now there’s nothing about YOU that’s defective – but what is it that’s messing with so many women’s insulin functions? Yes, there’s genetics, and we do know that PCOS can get started in the womb before we’re even born if our mom had insulin resistance, exposure to endocrine disruptors, or yet unknown factors. But we also know that antibiotics, modern diets, stress, environmental endocrine disruptor exposure, NSAIDS (i.e. ibuprofen, Motrin, etc), all affect our gut health. So does trauma. In turn, the type and diversity of bacteria in your gut impact insulin resistance. So this gut connection to insulin is an important one.
Here’s what we’re learning: At least some portion of women with PCOS along with its common companion, insulin resistance, have higher levels of specific types of bacteria that may alter biochemical pathways leading to and further increasing insulin resistance. Reduced production of what are called short chain fatty acids, fats that specifically help support the health of your gut lining and helpful bacteria, also drive insulin resistance and elevated androgen levels, and is more common in women with PCOS.
Studies showing lower microbial diversity in PCOS have found that this is connected to higher total testosterone levels – along with a higher incidence of common PCOS symptoms that come along with it, specifically unwanted hair growth. One reason is that lower amounts of bacteria decreases beta-glucuronidase production, an important enzyme that helps in hormone metabolism, in turn increasing androgen production.
Leaky gut and dysbiosis, in addition to insulin resistance, also cause chronic inflammation. This happens because the ‘gaps’ in the intestinal lining allow particles that were meant to stay in the gut – protein fragments from food, and something called lipopolysaccharides from even good gut bacteria, but more so from the not-so-great ones – to cross the intestinal lining and come into contact with the rich lymph and immune tissue, called the gut-associated lymphoid tissue (GALT) which underlines the inner gut layer. When the GALT ‘sees’ these fragments, it perceives them as a foreign invader, and much like when you get sick or get a vaccination, your body mounts an antibody attack against these perceived pathogens, and your inflammatory responses get dialed up to high volume to help in your body’s efforts to control the danger. As a result of a complex series of events, the downstream effect is a worsening of insulin resistance which increases androgen levels. When this occurs chronically, as it does for far too many of us, PCOS and other conditions (diabetes, for example) are the end game.
The research extends to other PCOS associations as well:
PCOS, Depression and Anxiety
A substantial number of women with PCOS struggle with depression and anxiety. It was long thought that this was due to weight problems and acne associated with PCOS causing self-esteem issues, but not all women with PCOS experience either of these, and not all women with higher weights or acne are depressed or anxious about it. So what’s the deal? It’s clear now that the much higher incidence of depression and anxiety in women with PCOS isn’t only related to the hormone imbalances that occur but to a powerful connection between what goes on in your intestines and your brain, called the gut-brain axis. In fact, dysbiosis is now a recognized and powerful driver of something called ‘brainflammation,’ biochemical changes that lead to inflammatory chemicals entering the bloodstream, making their way across the blood brain barrier, and causing anxiety and depression (this doesn’t just occur in PCOS and is an important reason gut health is important in the treatment of mental health challenges). Additionally, ‘bad gut bugs’ produce chemicals in the gut that also affect your mood. In one study, just adding a probiotic-rich yogurt to the diet, twice daily, substantially reduced anxiety in a group of women compared to those who didn’t receive the yogurt intervention. It was the probiotics that made the difference, not the yogurt itself.
Trouble Losing Weight
While PCOS affects women of all sizes, but weight challenges are common with this condition. PCOS can make it very hard for women to lose weight no matter how hard they try, which adds to frustration and challenges self-esteem in a culture that (falsely!) equates thinness with beauty, power, and health. A very strong connection links gut dysbiosis with increased weight, difficulty losing weight, and also obesity. This is in part due to the fact that strains of gut ‘bugs’ common in dysbiosis are able to extract significantly more calories from food, meaning that if you’re loaded up with this type, you’re going to get loaded up with more calories, making weight struggles more difficult for you even if you’re eating the same thing as your best friend who doesn’t have dysbiosis or PCOS. Further, the inflammation associated with dysbiosis and leaky gut is also a culprit in gaining and holding onto extra weight. As if that wasn’t problem enough, microorganisms present in dysbiosis can actually make you crave more sugar!
It’s clear that gut imbalances are, at the very least, present in many women with PCOS. But like so many interconnected relationships, insulin resistance, elevated androgens, and inflammation also cause dysbiosis and leaky gut. It’s not always clear which comes first, gut imbalances causing PCOS, or the other way around, but it’s clear that they are interrelated. The connection between PCOS and your gut has proven so significant that new research is looking at fecal transplant (yes, harvesting and transferring poop) as a possible treatment for PCOS. In fact, it’s already been shown to improve fertility and decrease androgen levels in an animal model of PCOS. But you certainly don’t have to go such length to heal your gut. I’m definitely not in my medical practice – because there are other ways to get there from here!
Binge Eating and Binge Eating Disorder
For unknown reasons, and quite possibly due wholly or in part to disruptions in the microbiome, women with PCOS have been shown to have impaired secretion a hormone called called leptin, which controls appetite and satiety – in short it tells our brains when to tell us to stop eating. In PCOS, leptin signaling goes offline, and women with PCOS might be getting the message that they're insatiably hunger, even when they've eaten. This is an important possible explanation for PCOS as a recently discovered cause of binge eating disorder – a problem that affects millions of women, leading to a traumatically difficult relationship with food where women blame themselves for ‘weakness’ and poor willpower, when it’s actually the condition causing this symptom in many.
So, before I say another word I want to emphasize something. By now, I hope you’ve gotten the memo: It’s not you, it’s not your fault if you can’t lose weight, if you’re struggling with anxiety or depression, if you’re binge eating, don’t know why, and find it hard to stop. The underlying disruptions that are causing PCOS are causing or contributing to all of these symptoms.
And that’s just what they are – symptoms of PCOS as a complex hormonal and metabolic syndrome, not symptoms of your willpower or you being emotionally broken.
Healing the PCOS Gut Connection
Not all women with PCOS have obvious digestive symptoms – nor even gut problems as a root cause, but because 90% of women do have some digestive issues, and so many have insulin resistance and chronic inflammation, so commonly associated with dysbiosis – and because gut health is so important for our overall health, I believe nourishing a healthy microbiome and addressing leaky gut if present, are important directions and low hanging fruit all women with PCOS should at least explore – and ideally, bring into balance .
Bringing your microbiome back into balance is actually not terribly complicated: a Mediterraneas-style diet, which I provide guidelines for in my book Hormone Intelligence, is the most important start. You want to get a higher balance of protein and fats in your diet compared to carbohydrates, to increase your fiber in the diet to at least 35 grams daily which you can do by getting 8 to 10 servings of veggies daily and 2 TBS of flax seeds in your daily diet, and increase your exercise. Taking a probiotic has been shown to improve insulin resistance and help with weight loss in some studies. The supplement berberine, an extract of the herb goldenseal, which is used to treat elevated blood sugar and insulin resistance, interestingly, also plays a role in the gut microbiome. In one tudy of eighty-nine insulin-resistant women with PCOS, taking 500 mg of berberine three times daily significantly improved metabolic markers of insulin resistance, outerperforning even metformin.
You can find more on gut and hormone health in this article and podcast: The Estrobolome: The Fascinating Way Your Gut Impacts Your Estrogen Levels. You can also check out PCOS: The Natural Prescription if you're looking for more on treating other root causes of PCOS, and I dive deeply into PCOS in my book Hormone Intelligence. Healing a leaky gut is a little more complex. I give you an overview here in this article and I offer you a protocol in my book, and guide you through one in my 28-Day Gut Reset.
As you move toward healing PCOS remember why it’s important not to blame or beat yourself up. And know that there’s something you can address. A healthy gut is so important – and studies show it’s very achievable – with substantial improvements in microbiome diversity and health in as little as 2 weeks with the right support.
Interested in learning how to heal your gut? I consider it so important to hormone health that from now thru June 8th, as part of my new book launch, you can join me for the NEW! 28-Day Gut Reset, a complete gut healing approach, totally FREE when you pre-order Hormone Intelligence! It’s easy as 1-2-3 as in literally 3 quick steps when you head over here. Hope to see you in the reset!
Baptiste C, et al. Insulin and hyperandrogenism in women with polycystic ovary syndrome. J Steroid Biochem Mol Biol. 2010 Oct; 122(1-3): 42–52.
Guo Y, et al. Association between polycystic ovary syndrome and gut microbiota. PLoS One. 2016 Apr 19;11(4):e0153196.
He F, Li Y. The gut microbial composition in polycystic ovary syndrome with insulin resistance: findings from a normal-weight population. J Ovarian Res. 2021;14(1):50. Published 2021 Mar 27.
Jobira B, Frank DN, Pyle L, Silveira LJ, Kelsey MM, Garcia-Reyes Y, Robertson CE, Ir D, Nadeau KJ, Cree-Green M. Obese Adolescents With PCOS Have Altered Biodiversity and Relative Abundance in Gastrointestinal Microbiota. J Clin Endocrinol Metab. 2020 Jun 1;105(6):e2134–44.
Lindheim L, Bashir M, Münzker J, et al. Alterations in Gut Microbiome Composition and Barrier Function Are Associated with Reproductive and Metabolic Defects in Women with Polycystic Ovary Syndrome (PCOS): A Pilot Study. PLoS One. 2017;12(1):e0168390.
Torres PJ, Siakowska M, Banaszewska B, et al. Gut Microbial Diversity in Women With Polycystic Ovary Syndrome Correlates With Hyperandrogenism. J Clin Endocrinol Metab. 2018;103(4):1502-1511.
Zhao X, Jiang Y, Xi H, Chen L, Feng X. Exploration of the Relationship Between Gut Microbiota and Polycystic Ovary Syndrome (PCOS): a Review. Geburtshilfe Frauenheilkd. 2020;80(2):161-171.