Labwork Suggestions for PCOS in Young Woman

(This is a sample entry from the SAFM Q&A Treasure Chest, a tool with hundreds of entries to support students with their client needs. Students get unlimited access as part of SAFM’s functional medicine training program.)

Student Question:

Hi Tracy,
I have a 19 year old patient who was diagnosed with PCOS when she was about 17. She has a history of weight fluctuations. She is 5’4″ and 158 lbs and would like to drop some weight. She is on Metformin 800mg/day as prescribed by her PCP. She is allergic to mold and takes Allegra everyday so that she can go to class. (Her classroom triggers her allergies – which is not a surprise! We discussed her addressing this issue with the college.)  She is aware of the link between PCOS and insulin resistance. She really wants to be proactive about her health. Our work will focus on keeping her blood sugar in check as well as finding ways to de-stress.   I would like current blood work, and she wishes to seek IgG testing for food sensitivities.  From a root cause perspective, what specific “everyday” labwork would you recommend?  Thanks!

SAFM Response:

It is unfortunate that we so often see hormone imbalances in women this young. As you note, PCOS is often correlated with insulin resistance. A high glycemic diet (perhaps exacerbated by the glycemic load of elevated stress hormones), leading to adaptively high insulin levels, can contribute to elevated androgens, inflammation, and low sex hormone binding globulin. High androgens (e.g., testosterone or DHT)  can cause a variety of symptoms in women that we associate with PCOS, including:

• Loss of hair where we want it (e.g., on the top of the head) and increasing hair growth where we don’t want it (e.g., on the face)
• Acne, including cystic acne
• Anger/irritation/moodiness
• Anovulation
  • Not all women with PCOS will have ovarian cysts. However, polycystic ovaries don’t ovulate consistently. Egg maturity is often impaired, producing many cysts with small, underdeveloped eggs.
  • Without ovulation, ovaries don’t produce progesterone to balance estrogenic effects in the body. Thus, ongoing PCOS can also lead to symptoms of estrogen dominance.

In addition, hyperinsulinemia also increases the risk of:

• Diabetes
• Hypertension
• Dyslipidemia (especially high triglycerides and low HDL)
• Obesity

Keep in mind that this dynamic may be present alongside optimal or even curiously lower (optimal?) blood sugar (both fasting glucose and/or HbA1c). Here are some conventional labs to consider for this woman in particular:

• Metabolic markers
  • Fasting Insulin
    • Very early stages of insulin resistance may not result in notably abnormal blood sugar or HbA1c, so checking insulin or c-peptide is an important baseline.
    • Subclinical elevations in the entire upper half of the normal range are notable. This is also a helpful lab to assess progress.
  • HbA1c
    • HbA1c may or may not be elevated, but watching the trend is helpful to check the progression of insulin resistance into hyperglycemia. Progressive hyperinsulinemia may be present for many years before blood sugar markers shift at all, and often there is a long period of surprisingly low (given their lifestyle) glucose values before they begin to increase. So cast a keen, clinical eye to markers whose values are objectively optimal yet misaligned with the patient’s presentation otherwise.
    • This is another important baseline as you work to reverse the insulin resistance and can be monitored over time to assess progress.
  • Triglycerides 
    • Triglycerides are often elevated in those with insulin resistance.
    • Aim for <100 mg/dl.
  • HDL
    • HDL is often low in those with insulin resistance.
    • Aim for >50 mg/dl in women.
• Immune system nutrients (given her allergy history)
  • Vitamin D 
  • Vitamin A
  • RBC Zinc 
• RBC magnesium (not serum – we are looking for tissue sufficiency)
  • Insulin resistance promotes poor cellular magnesium uptake and vice versa.
  • Suboptimal magnesium can also promote cramping and anxiety, two common symptoms in those with PCOS.
• Nutrient depletions due to metformin use
  • Serum B12, MMA, and RBC Folate
  • Metformin use can lead to B vitamin depletion, especially B12 and perhaps folate as well. Both are needed for methylation, which is needed to degrade histamine (for relief from her allergies) and to produce glutathione to help protect the body from the oxidative effects of excessive insulin and/or blood sugar.
• CoQ10
• Androgens 
  • Total and free testosterone
  • DHT
• Full thyroid panel
  • TSH, Free T4, Free T3, and both TPO and TG antibodies.
  • Given her fluctuating weight, it is prudent to also check for a thyroid imbalance (sex hormones have a significant effect on thyroid hormones).

If she can afford some inexpensive functional panels at some point later in your work with her, here are two to consider:

• IgG with Complement food panel
  • Persistent, high histamine secretion promotes enhanced intestinal permeability and damage to the protective mucosal lining of the intestines. This loss of barrier function may increase the presence of food reactivity.
  • Many people with mold allergies have food sensitivities due to a dysregulated immune system.
• IgE testing
  • Many people have only identified allergies via skin prick testing.
  • Blood IgE testing can be done to assess a wider array of food and environmental allergens. This may be helpful if she (or you) is suspicious of other allergies.

Assuming insulin resistance is confirmed, you can reference the labs, nutrition, and supplement recommendations in the Reversing Metabolic Dysfunction clinical course. Please also see this additional TC post on Inositol and Insulin Resistance.

Also, regarding her allergies, check out this post on Histamine Overload.