Adrenal PCOS: Surprising Ways Stress Affects Your Hormones

Myths and truths about PCOS

There are many misconceptions about PCOS that cause confusion, misdiagnosis, and mistreatment in women who are experiencing the multitude of symptoms associated with the disorder.

Despite the name polycystic ovarian syndrome, having cystic ovaries isn’t a requirement to be diagnosed with PCOS.

In fact, the NIH has concluded that the name PCOS should be changed, as the name causes confusion and doesn’t reflect “the complex metabolic, hypothalamic, pituitary, ovarian, and adrenal interactions that characterize the syndrome.” 

Many people, including healthcare professionals, also don’t even realize that being overweight is not a requirement of having PCOS. It’s estimated that one-third to one-half of women with PCOS are at normal weight or underweight and that being overweight or obese does not increase the risk of developing the condition.

While weight loss in women who are overweight may be beneficial, this recommendation isn’t useful for women with PCOS symptoms who aren’t overweight. And using birth control pills as a treatment for amenorrhea is often unnecessary and simply masks a deeper diet and lifestyle problem.

Believing that PCOS is solely genetic, due to excess weight, or simply caused by cystic ovaries that can be treated using hormone replacement is a dangerous assumption that prevents many women from getting the help they need.

Elevated androgenic hormones: not just an ovarian problem

One of the primary diagnostic criteria of PCOS is elevated androgens, “male” sex hormones that cause unwanted hair growth, acne, and reproductive dysfunction.

The two main androgenic hormones causing these symptoms in women are testosterone and androstenedione. Other androgens include dihydrotestosterone (DHT), dehydroepiandrosterone (DHEA), and dehydroepiandrosterone sulfate (DHEA-S).

It’s normal for women to have some androgenic hormones in their system; in fact, low testosterone in women is associated with low sex drive, bone loss, chronic fatigue, weight gain, mood disorders, and cognitive issues. Calling them “male” sex hormones is a misnomer.

However, when these hormones are elevated, as is pervasive in PCOS, symptoms of androgen excess begin to manifest. For some women, this affects their menstrual function and fertility. For others, they continue to menstruate but struggle with physical changes like unwanted hair growth, acne, and weight gain.

And one of the primary confusions over PCOS is which organ these androgens come from. While the ovaries are typically blamed for elevated androgens in PCOS, it’s estimated that 20 to 30 percent of women with PCOS have adrenal androgen excess. 

The adrenal glands produce all of the DHEA sulfate (DHEA-S) and 80 percent of the DHEA in the body. The adrenals also produce 50 percent of androstenedione and 25 percent of circulating testosterone. Since DHEA-S and 11-androstenedione are not secreted by the ovaries, they are used as markers of adrenal androgen secretion. 

How your adrenals cause PCOS symptoms

The chart below shows how both the adrenal glands and the ovaries impact androgenic hormone production. It illustrates how the hypothalamus and pituitary gland, both located in your brain, release hormones that drive the cycle of high androgen output, insulin resistance, increased abdominal fat, and impaired glucose sensitivity. These systems are called the hypothalamus-pituitary-adrenal or -gonadal axes. (HPA/HPG.)

While insulin resistance and elevated insulin often drive the ovarian production of testosterone, it is the hypothalamus-pituitary-adrenal (HPA) axis that stimulates the production of DHEA/DHEA-S and androstenedione. These hormones can be converted to testosterone by peripheral tissues in the body. This process can occur independently from the ovaries and any involvement with insulin.

This means that a woman with PCOS symptoms could have normally functioning ovaries with no cysts and no insulin resistance, yet still fit the symptomatic profile of the syndrome.

There is some controversy over whether elevated androgens cause insulin resistance or if insulin resistance happens first. The most likely answer is “it depends”; some women likely develop insulin resistance first, while others develop elevated androgens first.

Either way, it’s clear that not only is the brain heavily involved in the output of androgenic hormones, but that the adrenals may also be responsible for PCOS symptoms in a subset of patients.

How stress impacts your hormones

The pituitary gland, stimulated by the brain via the hypothalamus, secretes adrenocorticotropic hormone (ACTH) in response to stress. ACTH then stimulates the adrenal glands to produce cortisol, adrenaline, and noradrenaline. In addition to these stress hormones, ACTH also stimulates the production of adrenal androgen hormones, including DHEA, DHEA-S, and androstenedione.

ACTH follows a diurnal rhythm, meaning it’s higher in the morning and lower in the evening, but it also spikes in response to physical and emotional stress. Stress activates the HPA axis, raising ACTH and cortisol output. Cortisol release then down-regulates ACTH production in a negative feedback loop.

ACTH also stimulates the production of DHEA/DHEA-S and androstenedione, which help protect the brain from the negative effects of cortisol and other stress hormones. But as you learned earlier, these hormones also cause the symptoms of elevated androgens seen in PCOS.

And these androgenic hormones do not affect the release of ACTH, unlike cortisol, meaning there is no feedback regulatory loop that controls androgen secretion in women. 

Research also shows that women who are under extreme chronic stress situations (for example, PTSD) have a markedly increased DHEA response to ACTH stimulation, as well as a higher ACTH response to stress and stimulation from the hypothalamic hormones. They also have higher levels of baseline DHEA compared to healthy controls, and traumatized women with the highest DHEA had the least severe PTSD symptoms.

This means that women who are under chronic stress not only have more opportunities for elevated ACTH and thus elevated androgens, but their hormones may also start to react more severely to stressful situations. It also suggests that a higher amount of DHEA could be the body’s way of protecting the brain from the long-term effects of chronic stress.

Where does chronic stress come from?

To review, you’ve learned so far that:

• Elevated androgens like testosterone and androstenedione contribute to PCOS symptoms like menstrual dysfunction, unwanted hair growth, weight gain, acne, and mood disorders
• The adrenal glands are responsible for at least 20 to 30 percent of the elevated androgens seen in PCOS
• Chronic stress elevates ACTH, which stimulates androgen secretion, for which there is no negative feedback loop
• Androgen hormones are protective against the long-term effects of chronically elevated stress hormones like cortisol and adrenaline

I hope it’s perfectly clear by now that chronic stress is a major contributor to the development of PCOS symptoms, especially in normal or underweight women with non-cystic ovaries and normal insulin sensitivity.

Elevated androgens, while causing PCOS symptoms, may be the body’s way of protecting the brain from the harmful effects of chronic stress.

And chronic stress is everywhere these days; from long work weeks and poor sleep to new babies and aging parents, to constant negative thoughts about our bodies and physical appearance, women are bombarded by stress from every direction.

Combine this with traumatic events, acute illness and infections, gut dysbiosis, and disrupted sleep, and it’s no wonder that so many women come to me complaining of reproductive dysfunction or amenorrhea, weight loss resistance, blood sugar fluctuations, anxiety and/or depression, acne, chronic fatigue, and hormonal imbalances.

The worst part is that the more stress drives up our androgenic hormones, the more our weight, skin, and hair growth is affected, and the harder we struggle to improve our appearance.

For some women, this drives them to restrict their diet further, diet harder, work out more often and more intensely, and push their bodies to the brink of exhaustion. It’s a vicious cycle that I see all the time in my practice. (I’ve even struggled with this problem myself.)

Don’t get me wrong: there are plenty of women whose PCOS is caused by a poor diet, inadequate exercise, too many refined carbohydrates and sugars, and a generally unhealthy lifestyle.

But if you’re breaking your back trying to follow the perfect low-carb Paleo diet, going to CrossFit five to six days per week, and finding yourself gaining weight, losing your menstrual function, growing hair in weird places, developing adult acne when you had clear skin as a teen, or simply feeling like a truck hit you every morning you wake up, it may be chronic stress causing your physical symptoms and hormonal imbalances.

How to kick stress to the curb

Getting your stress under control is a challenging task, and unfortunately, there’s no quick fix for the long-term effects of regular stress. Our culture thrives on stress and perfectionism, and many people push themselves past their physical limits in an attempt to “look better naked,” make more money, have more possessions, and live an envy-worthy life that looks great on Instagram.

If you’re ready to break the cycle of stress and fear-based health pursuits, here are a few tips to get you started in the right direction.

Diet

As I explained before, many conventional recommendations for PCOS involve losing weight and increasing insulin sensitivity, primarily through reducing carbohydrate intake, cutting calories, and increasing physical activity. These recommendations work well for the woman eating a typical American diet and not moving enough.

But if you’re already eating a low-carbohydrate Paleo diet and your symptoms are getting worse instead of better, you might be a woman whose body is responding negatively to the stress of inadequate calorie and carbohydrate intake.

First, start by assessing your total calorie intake. One benefit of a Paleo diet is a spontaneous reduction in calorie intake, but for women who are active, this can take their intake too low to support their exercise routine. Combine this with poor body image and a desire to lose body fat, and many women are taking their food intake even lower, either consciously or unconsciously.

Chronic calorie deficits over a period of months or years raise stress hormones as your body tries to conserve energy and keep blood sugar stable. Make sure you are not eating less than 80 percent of your estimated calorie needs on a daily basis if you are trying to lose weight, and consider taking a break from any calorie deficit for a few weeks or months.

Too little carbohydrate intake can have similar impacts as inadequate calories, especially for highly active women doing glucose-demanding activities like weightlifting and CrossFit. Use this article to guide your carbohydrate intake depending on your health needs and activity levels.

Eating a calorie-appropriate and macronutrient-balanced diet is a huge step for many of the women I work with in my private practice to improve their hormonal profile.

Exercise

Again, the typical recommendation for a woman with PCOS is to exercise more. But if you’re already hitting the CrossFit box five days a week, running 20 miles a week, or squeezing bootcamp classes in at 5:30 a.m. every morning, you might be damaging your hormones by exercising too much.

Overtraining is more of a symptom of under-recovery, so eating and sleeping enough and taking at least one to two rest days per week can help minimize the impact of a high training volume and prevent hormonal disruption.

If you’re concerned that overexercising is driving your hormonal imbalances, check out this article on exercising with “adrenal fatigue” (HPA axis dysfunction) for guidelines on how to appropriately scale back your exercise so that you’re maintaining strength and fitness while allowing your hormones to recover.

Sleep

Admittedly, sleep is one of those health behaviors that I still struggle to prioritize. And yet the benefits to my energy, performance, and cognitive function I experience when I get adequate, high-quality sleep are undeniable.

One of the most common factors impacting our ability to sleep well is our use of electronic devices after the sun has gone down. Check out the guidelines in this article for ideas on how to mitigate the effects of light exposure at night so that your sleep is more restorative.

http://chriskresser.com/adrenal-pcos-surprising-ways-stress-affects-your-hormones/