Your Comprehensive guide to training with PCOS (Part 1)
For years, women’s health has been neglected by mainstream medicine. From male doctors not listening to their female patients to male researchers not including women in their studies, there is an incredible lack of research focusing on women's health issues. PCOS is a hormonal disorder that affects as many as 20% of females of reproductive age and almost every research paper I read in preparation for this article started by citing lifestyle interventions as the most important part of any treatment plan. And yet these same papers cannot give strong ‘evidence based’ recommendations for how to create exercise programs and nutritional strategies to support these women because there just is just not enough research. In the International Evidence-based Guideline for the assessment and management of polycystic ovary syndrome for 2023, they note that there are only 18 studies directly looking at the effects of lifestyle interventions on women with PCOS. This is a massive problem for anyone with PCOS looking to take their health into their own hands.
So where does that leave fitness professionals who wish to give their female clients the best evidence based information? It means we have extrapolate. To supplement what little direct evidence we have, I created this guide by relying on principles of physiology and applied those principles to the metabolic and hormonal disorder that is PCOS. At a fundamental level, PCOS is marked by two things: insulin resistance and a hormonal imbalance characterized by excess testosterone. What causes PCOS? Aside from those whom it may be genetically inherited, insulin resistance is thought to be the culprit. Insulin resistance is seen in 75% of lean women and 90% of obese women with PCOS and causes excess testosterone via its impact on the ovaries. But while PCOS may not be curable, we absolutely have the power to improve our insulin sensitivity and reverse some of the negative impacts of insulin resistance through exercise, nutrition, and medication. By the end of this series anyone with PCOS should feel empowered with the knowledge of how you should exercise and what you should eat to thrive with this condition.
As I mentioned previously, insulin resistance is the defining factor of PCOS. But what is insulin resistance? Well, whenever we eat carbohydrates they are broken down into glucose, which circulates in our blood. And while carbs have been demonized by popular media, glucose is your body’s preferred source of fuel. Your brain runs on it and if we don’t eat enough carbs to fuel our brain it has to turn to fats or proteins to do so, which is not as efficient a process. Any time you are doing any type of high intensity exercise, from resistance training to chasing after your kid, your body is using glucose, either stored in our muscle and liver or floating in our blood stream.
Carbohydrates are essential, but managing the breakdown of carbohydrates into glucose is also very important. If we have too much glucose in our blood at one time, or too little, we will run into major issues. Have you ever felt like you were going to pass out after an intense workout? Most likely your blood sugar dropped too quickly. Luckily for most of us, we don’t need to worry about this relationship, because insulin does it for us. When we eat a lot of carbs and our blood sugar levels rise, insulin rises with it to move that glucose from our blood stream into our fat, muscle, and liver cells by stimulating specific transport mechanisms in those cells. In theory, this process should balance our blood glucose perfectly. But, sometimes this process does not work as intended. When our cells become less sensitive to insulin, our pancreas has to produce more insulin than before to get the same effect. Imagine you are talking to someone at a normal conversational level; you can both hear each other and communicate fine. Insulin resistance is like your muscle and liver cells putting on noise canceling headphones; now the other person has to yell louder and louder for you to hear what they are saying at all.
But why does this happen? Outside of genetic factors, those born with type 1 diabetes for example, the mechanism of insulin resistance is unfortunately very simple: too much body fat in specific parts of our body. There are two types of body fat, subcutaneous and visceral fat. Subcutaneous fat lies just below the skin and should not be thought of as a health problem whatsoever. Visceral fat, on the other hand, is fat that infiltrates our muscle cells and liver. When fat starts to infiltrate our muscle and liver it decreases their ability to respond to insulin, thus starting the progression of this disease. Unchecked, insulin resistance can eventually evolve into type 2 diabetes, where the pancreas no longer produces any insulin any more at all. Imagine someone starts yelling at you louder and louder, trying desperately for you to hear them. But eventually you just sort of tune them out, and in response, the other person just gives up. That is type 2 diabetes. Importantly, If you have PCOS you are much more likely to get type 2 diabetes.
As insulin resistance is the primary culprit of PCOS, and excess subcutaneous fat is the primary culprit for insulin resistance, we start to have a clear understanding of what how we should implement exercise and nutrition strategies. Let’s discuss this more in part 2.
