PCOS, Progesterone Deficiency and Gluten Intolerance January 18, 2013 This month’s guest post is written by Michelle Shwarz, MSEd, a trained mental health clinician and currently a 4th year doctoral student of Public Health at Temple University. Her research focus is on psychological aspects of PCOS. She is also the organizer of Philadelphia’s PCOS Meetup Support Group Michelle is not a dietitian. Please consult a professional before making changes to your lifestyle. You’ve been diagnosed with PCOS and you’re doing everything you’re supposed to do. You’ve been eating right, increasing your physical activity, taking your medication regularly, and keeping your stress under control. Yet, you still don’t feel quite right. You’re moody and your PMS is—well let’s just say, we should avoid you for the next 5-7 days. You’re particularly tired even though you’re getting enough sleep. Your shoes are suddenly too small, your rings don’t fit, but your weight hasn’t changed. You notice that you’ve been getting headaches more often than normal. Maybe most importantly, you are unable to get pregnant. Does this sound like you? The possible culprit is progesterone deficiency. PCOS can be worsened or caused by a progesterone deficiency. Progesterone is important, not just for implantation and sustaining pregnancy, but also for keeping our immune systems healthy in our gut. What is the role of progesterone? During the follicular phase of the menstrual cycle (the part between the period and ovulation), progesterone is pretty low. Estrogen is busy at work doing prepping us for ovulation by promoting fertile cervical fluid and possible pregnancy. Once we ovulate, the sack that held the egg (the corpus luteum) is responsible for releasing progesterone, which helps prepare the lining of the uterus to attach a fertilized egg. It’s also known as the warming hormone because it causes our basal body temperature (BBT) to increase about half a degree after ovulation. After about 4-8 days, the corpus luteum starts to die off. If an embryo was created and successfully implanted, it will soon take over the progesterone production for the remainder of the pregnancy. If not, you will get your period. If you have a deficiency in progesterone, you may have difficulty getting an embryo to stick (chemical pregnancies), have early miscarriages because you’re not producing enough progesterone to sustain the pregnancy, or even quasi ovulating (you’ll have to look up something called luteinized unruptured follicular syndrome), where it looks ovulation occurs, but the luteinized follicle never releases an egg, but does release progesterone. Bottom line, a lot can go wrong on the way to pregnancy with progesterone deficiency. For those of you who chart your BBT, another sign of progesterone deficiency is a luteal phase (the phase that begins the day of ovulation until the first day of your period) that is less than 12 days long. What came first, PCOS or progesterone deficiency? Unfortunately the jury is still out on that one. Over 20 years ago, some researchers stumbled upon the PCOS-progesterone deficiency connection (1) but it never gained enough steam for more research. However, it’s likely that PCOS can cause progesterone deficiency and progesterone deficiency can cause PCOS. A small Indian study found that treating insulin resistance with metformin in women with PCOS also improved progesterone levels, which incidentally may be one of the reasons decreasing insulin resistance by any means (medication, diet, and/or exercise) also improves fertility.(1) Other names for progesterone deficiency are estrogen dominance and luteal phase deficiency. The reason for this is if your progesterone isn’t sufficient, estrogen is trying to take over. A sign of this is that you may have a lot of fertile-looking cervical mucus during the luteal phase of your cycle and your breasts may enlarge or be especially painful. So, to recap, progesterone deficiency can result is any of the following symptoms (3): * Moodiness, anxiety, depression * Infertility, miscarriage * Menstrual irregularities including heavy and/or unusually painful periods * PMS or PMDD * Headaches, migraines * Increased breast issues, including pain, tenderness, especially during luteal phase * Endometriosis * Long-term issues during peri-menopause, menopause such as excessive hot flashes and night sweats. However, many premenopausal women also complain of hot flashes and night sweats as well. * Weight gain, difficulty losing weight, bloating Pause—did that last symptom catch your attention? Well, this blog post is about PCOS, progesterone deficiency, AND gluten intolerance. So what’s the connection? The medical literature has readily established a strong association between gluten sensitivity and hormonal issues, especially with progesterone. At its worst, gluten sensitivity can actually be an autoimmune disease called Celiac disease, a condition that is treated with absolute abstention from gluten (i.e.- can’t eat it EVER). Those who do not have celiac disease but are gluten sensitive do not have to be as careful, but should typically avoid gluten when possible. If you read many PCOS blogs, you may notice a huge amount of information about inflammation, fighting inflammation, how PCOS is caused by inflammation, how inflammation makes everything in your body go wrong. Well, no surprises here then. If you are gluten sensitive, every time you eat gluten, you cause inflammation in your body, which could contribute to lots of other disorders, heart disease, arthritis, diabetes. You get the picture. But the specific mechanism that links gluten and your hormones are in your adrenal glands. These little glands that sit above your kidneys and are responsible for your metabolism, keeping stress in check, and producing another hormone which is required to make progesterone, testosterone, and estrogen. Too much stress, the adrenals go in to overdrive and produce more cortisol to keep us going, and as a result, the sex hormones take a back seat. When we’re constantly inflamed, the adrenals read this as stress. Instead of making the good sex hormones, our adrenals are simply working to keep us alive pumping tons of cortisol (you’ve seen this commercial, the one claiming that cortisol causes belly fat—yep, it’s true). And to add insult to injury, the gluten not only messes with the hormone production in our bodies, it wreaks total havoc on our gut. Odds are good that in addition to being gluten intolerant, you’re also bit lactose intolerance, and any additional source of estrogen (dairy and soy) affects you way more than your non-gluten sensitive friends. So in addition to the symptoms mentioned above, maybe you’re also experiencing: * Trouble sleeping (difficulty falling asleep, not experiencing refreshing sleep) * General fatigue – all the time, even with enough sleep and exercise * Generalized joint and muscle aches, maybe diagnosed with fibromyalgia or chronic fatigue syndrome * Weight gain for no reason; resistance to weight loss despite healthy diet and exercise * You’re sick all the time. Colds/flus, infections (bacterial, yeast) * Lightheadedness * Fogginess/ poor memory/difficulty concentrating * Low blood sugar – post-prandial hypoglycemia(after you eat a meal, you feel even more tired and hungry than before you ate) * Long-term effects: allergies (environmental: hay fever, food allergies), arthritis, asthma, hypothyroidism If you’re freaking out right now, take a big, deep breath. There is good news. By simply eliminating gluten from your diet, all of these symptoms are entirely reversible. Within a week, you can start feeling like yourself again. Within a month, you may even get a normal period. Within 6 months, perhaps a pregnancy. Within a few years—you may be feeling better than ever. I’m not promising anything here, but it’s a small start and an excellent hypothesis. It’s a cost-free opportunity to play Sherlock Holmes with your health to see if you may be gluten intolerant. For more information about gluten and gluten-free foods, see Amy’s blog post http://pcosdiva.com/2012/03/go-gluten-free-for-pcos-part-1. For her gluten-free meal plans see www.pcosmealplans.com Why hasn’t my doctor thought of this? Researchers like me are often responsible for “connecting the dots.” My job is to pose hypotheses and offer reasonable explanations based on what we know about the research that has been done. Your doctor’s job is to treat you based on your individual symptoms during a very short appointment with the tools they have in their medical tool box. They may not be aware of these connections because they would have to read up on all of the latest and greatest research and put it together with what we already know. If it’s not common practice, odds are, they’ll miss it or they may not be willing to test for it because it’s a little off the beaten path. You know your body better than anyone and you have a right to say to your doctor, “hey, do you think I may have progesterone deficiency or be gluten intolerant or have celiac disease?” Most good doctors would be willing to investigate with you. Final thoughts: Be careful when evaluating your own symptoms. Many symptoms of progesterone deficiency are similar to those of hypothyroidism, congenital adrenal hyperplasia, and anemia, all of which frequently co-occur with PCOS, progesterone deficiency, and gluten sensitivity. Always ask your doctor first, especially if you are experiencing a lot of these symptoms. If your doctor wants to test you for Celiac Disease, you should not give up gluten until after the test. If your Celiac Disease panel is negative but you suspect you may be gluten intolerant, you may cut gluten from your diet. Gluten intolerance is best diagnosed through avoidance. In just a few days, you may start noticing improvements. Please be patient. It may take up to 2-3 years for your body to fully heal and return to normal functioning. In my opinion, it’s well worth the investment. 1) Meenakumari, KJ, Agarwal, S, Krishna, A, Pandey, LK, Effects of metformin treatment on luteal phase progesterone concentration in polycystic ovary syndrome. Braz J Med Biol Res. 2004. 37(11): 1637-44. http://www.ncbi.nlm.nih.gov/pubmed/15517078 2) Filicori, M, Flamigni, C, Meriggiola, MC, Ferrari, P, Michelacci, L, et al. Endocrine response determines the clinical outcome of pulsatile gonadotropin-releasing hormone ovulation induction in different ovulatory disorders. J Clin Endocrinol Metab, (1991),72:965–972. http://www.ncbi.nlm.nih.gov/pubmed?term=1902487[uid] 3) Practice Committee of the American Society for Reproductive Medicine. The clinical relevance of luteal phase deficiency: a committee opinion. Fertil Steril. (2012) 98(5): 1112-7. http://www.ncbi.nlm.nih.gov/pubmed/22819186 4) Ch’ng CL, Jones, MK, Kingham JG. Celiac disease and autoimmune thyroid disease. Clin Med Res. (2007),5(3):184-92. http://www.ncbi.nlm.nih.gov/pubmed/18056028 5) Collin P, Kaukinen K, Valimaki M, Salmi J. Endocrinological disorders and celiac disease. Endocr Rev. (2002), 23(4): 464-83. 6) Toscano V, Conti FG, Anastasi E, Mariani P, Tiberti C, et al. Importance of gluten in the induction of endocrine autoantibodies and organ dysfunction in adolescent celiac patients. Am J Gastroenterol (2000), 95(7): 1742-8. http://www.ncbi.nlm.nih.gov/pubmed/10925978 This blog post does not constitute medical advice. I am not a physician. Recommendations made in the post are for educational purposes only. It is not intended nor implied to be a substitute for professional medical advice. The reader should always consult her healthcare provider to determine the appropriateness of the information for their own situation or if they have any questions regarding a medical condition or treatment plan.