Lowering Testosterone With PCOS
One of the hallmark traits of PCOS is elevated testosterone levels. It’s one of the Rotterdam Criteria required for a PCOS diagnosis, and clinicians will either observe elevated androgens through observed clinical symptoms, or through biometric markers in our blood.
What is testosterone?
In females, testosterone is a hormone produced by both the ovaries and the adrenal glands. The hypothalamus-pituitary gonadal axis, connecting the brain and reproductive organs, stimulate ovarian testosterone production. The hypothalamus and pituitary gland regulate how much is produced. Our adrenal glands produce dehydroepiandrosterone (DHEA), which is a precursor to testosterone. Keep these factors in mind. This means that anything in our lives that can impact the hypothalamus, pituitary gland, and the adrenal glands, can lead to an imbalance in testosterone.
Testosterone is converted into estradiol in the female body, and estradiol helps to regulate reproductive function. When testosterone is in proper balance in the female body, it helps to promote cycle regularity, plays a key role in bone formation alongside estrogen, maintains metabolic health, promotes awareness, working memory and overall cognitive function, and maintains libido. Testosterone plays an important role in the female body, and the goal is to balance it, not eliminate it.
Symptoms of Elevated Testosterone
Elevated testosterone is associated with some of the most frustrating PCOS symptoms. Think about things like loss of hair on the head, acne, facial hair growth, or hair growth on the neck and back. Elevated testosterone is also associated with increased waist circumference, and particular difficulty getting rid of belly fat compared to other areas of the body. You might not sleep well, and might feel like when you sweat, it’s in excess or it’s particularly smelly. You may not menstruate, or may struggle with infertility. And, it can worsen insulin resistance or blood sugar problems. It may also lead to smaller breasts. Lastly, it can exacerbate mood swings and irritability.
If you test your testosterone levels…
There is a rather substantial range that is considered “normal”. Testosterone levels in females typically peak in the 30s-40s, and then begin to decline. It tends to be highest in the morning, so testing your testosterone levels at their peak will help you understand whether levels are in excess. With a blood test, you can test for:
Total testosterone
Free testosterone (the active form in the blood)
DHEA Sulfate (recall this is the precursor to testosterone produced by the adrenal glands, but often it’s not super high in PCOS patients)
My experience with this has been…interesting. Although my total testosterone levels were within the “normal range”, which are reported as 15 to 70 ng/dL, (which is a HUGE range by the way), I worked with a functional medicine doctor who advised the normal range was far too high. She educated me that the normal range and the optimal range are two different things, and for my age (27 at the time), she wanted to see me more in the 20-30 ng/dL range for total testosterone. So, my testosterone levels of 55 ng/dL were wildly outside of that, and were driving many of my symptoms, most difficult of which was severe acne.
The DUTCH Test
Another test that can help illuminate whether you have a testosterone imbalance is the DUTCH test. This urine test allows providers to see your total DHEA production (not just DHEA sulfate, also takes into account DHEA androsterone (DHEA-A) and etiocholanolone (DHEA-E)), total testosterone, and the way your testosterone is being metabolized. Low levels of DHEA-sulfate can indicate inflammation is at play, blocking sulfation of DHEA. However if we see higher DHEA-A compared to DHEA-E, we have more androgenic metabolites. This means there is a higher likelihood that testosterone will be converted via the 5-alpha pathway into DHT, which has 3x more powerful androgenic effects than testosterone.
PCOS, Insulin Resistance and Testosterone
Insulin resistance is extremely common with PCOS and it contributes to androgenic effects. Insulin resistance effectively strengthens the 5-alpha pathway that is responsible for conversion of testosterone to DHT. Insulin can also promote testosterone synthesis and reduce sex hormone-binding globulin. SHBG binds to testosterone to prevent it from metabolizing too quickly. Thus insulin is both increasing testosterone while decreasing a protein that can help slow its effects. Therefore one of the key ways to get a handle on our testosterone levels is to improve our insulin sensitivity.
Effects on the Brain and Adrenals
We said earlier that anything that impacts the hypothalamus, pituitary gland, and adrenal glands can influence our testosterone production. The hypothalamus integrates information from various regions of the brain, including the frontal lobes, hippocampus, thalamus and the brain stem for integration of sensory and affective information. It is the link between our nervous and endocrine systems. It maintains balance in the body, receiving information from all parts of the nervous system. It releases and inhibits hormones, signaling what hormones the pituitary gland needs to release. It is also responsible for temperature regulation, autonomic nervous system regulation, stress and inflammatory response, appetite control, sleep, and nature of social connection. PCOS affects both the nervous and endocrine systems, so the hypothalamus can receive improper signals and inform the pituitary gland to release too much or too little of certain hormones, including testosterone.
The adrenal glands release hormones directly into the bloodstream, including cortisol, aldosterone, DHEA/androgenic steroids, adrenaline and norepinephrine. The adrenal glands are influenced by the pituitary gland in the brain, which we mentioned receive signals from the hypothalamus.
Pay mind to your mind…
This means we have to pay particular attention to factors that influence the hypothalamus when considering how to lower testosterone levels. The hypothalamus responds to a host of factors including:
Environmental stimuli and cues happening outside of the body
What we hear, touch, see, smell and sense
Perception of pain and temperature
Stress signals and perceived threats whether they are legitimate or not
The hypothalamus is a center of the limbic system, which controls the way we respond emotionally and behaviorally to different situations. Our emotional responses send cues to the hypothalamus
Nourishment and nutrition status via the vagus nerve
Lowering testosterone levels with PCOS using lifestyle
1. STRESS REDUCTION
A small randomized controlled trial evaluated the effects of mindful yoga practices on testosterone levels of those with PCOS versus those without a mindful practice over the course of 3 months. Those who had the mindfulness intervention had significantly lower free testosterone levels and lower dehydroepiandrosterone levels. Anxiety and depression symptoms also improved. Effective stress reduction will look different from person to person. Trying out different tactics to discover what works for you is your best bet.
2. SPEARMINT TEA
A 30 day randomized controlled trial evaluated the effects of drinking spearmint tea twice per day. Free and total testosterone levels were significantly reduced, and both luteinizing hormone and follicle stimulating hormone levels increased in the same time period. Note: with lifestyle interventions, we have to be patient for results. Our hormone levels often change behind the scenes before we see the physical effects/benefits of change.
3. ZINC-RICH FOODS
Zinc can help to decrease testosterone through reduction of the enzyme 5-alpha-reductase that converts testosterone into the androgen DHT, which basically strengthens the effects of testosterone. A 2020 meta-analysis of 36 randomized controlled studies on reproductive, pre and post menopausal women was conducted to showcase the effect of zinc supplementation on the female reproductive system. Studies primarily provided zinc in the form of zinc sulfate, and did consistently reveal a positive effect. Specifically, various markers of insulin resistance improved, including insulin concentration, lipid concentrations, total cholesterol and triglycerides. The meta-analysis could not confirm that the decrease in testosterone and DHEAs was due solely to zinc supplementation, since some studies paired zinc with magnesium, or calcium and Vitamin D.
The Recommended Dietary Allowance for female adults 19+ is 8 mg per day, and 11 mg during pregnancy, and 12 mg if lactating. Do not exceed 40 mg per day. You can get your RDA through:
Oysters
Crab
Sardines
Shrimp
Pumpkin seeds
Greek yogurt
Beef
Poultry
Pork
Lentils
Chickpeas
Brown rice
4. LIMIT EXPOSURE TO ENDOCRINE DISRUPTING CHEMICALS THAT CAN INCREASE TESTOSTERONE PRODUCTION
Dust and vacuum regularly
Choose nontoxic products when possible
Wash your hands often
Swap plastics where possible
Drink filtered water
Prioritize whole foods
Follow the Dirty Dozen and Clean 15 when choosing organic produce
5. BODY MOVEMENT AND EXERCISE
A randomized controlled trial assigned groups of PCOS patients to either HIIT training every other day for 12 weeks, or strength training. Both groups showed reductions in serum testosterone levels, body fat percentage, and body mass index. This further suggests that exploring the exercise or body movement that you enjoy and lights you up, and even mixing up your exercise routine, can be hugely beneficial in reducing testosterone levels!
6. BALANCE MEALS TO LOWER INSULIN RESISTANCE
Did you know that insulin resistance and testosterone tend to move in unison in females? That means, multiple studies have shown an association between the two: as insulin resistance increases, so too does testosterone, and vice versa. If we can improve insulin resistance, or our sensitivity to insulin, we can also predict a decrease in testosterone levels! And to do this, we can aim for 30g of protein at each meal, paired with plenty of fibrous veggies like leafy greens, some fat like yummy avocado or olive oil, and complex carbohydrates!