By Dr. Shawna Darou, ND
A very common time for women to be diagnosed with PCOS is after coming off the birth control pill. The pill suppresses the communication between the brain and your ovaries which stops ovulation. When most women stop the pill, this communication will come back right away along with regular ovulation and regular periods. Some women however, will experience ovulation suppression for months or even years after the pill, meaning they won’t have a period at all. In these cases, we need an accurate diagnosis in order to treat each case appropriately.
For women with absent periods after the pill, there are three more likely diagnoses:
- Hypothalamic amenorrhea – meaning the communication between the hypothalamus – pituitary – ovaries is disrupted causing a lack of ovulation and menstruation. This is most common with women who are underweight, extremely stressed or over-exercising.
- Pill-induced PCOS – where periods were regular before starting the birth control pill, but absent afterwards along with some signs of PCOS such as acne, a high LH to FSH ration and possibly cysts on the ovaries.
- True PCOS – where periods were irregular before starting the birth control pill, and other signs of PCOS such as insulin resistance, hirsutism, acne and ovarian cysts are likely present. (Remember that many women with PCOS do not have all of the symptoms!)
Chart to diagnose the cause of absent menstruation after stopping oral contraceptives:
| Hypothalamic amenorrhea | Pill-induced PCOS | True PCOS | |
| Period regularity | No periods after stopping the pill | No periods after stopping the pill | No periods or irregular periods after stopping the pill |
| Period regularity before the pill | Absent or normal | Regular | Irregular |
| Presence of acne | No | Yes or No | Yes (likely)* |
| Insulin resistance | None | None | Yes (likely)* |
| Polycystic ovaries seen on ultrasound | No | Possibly | Yes (likely)* |
| LH / FSH ratio | Both LH and FSH are low | High LH: FSH ratio | High LH: FSH ratio |
| Estrogen level | Low | Normal | Normal |
| Temporary / long-term | Temporary | Temporary | Long-term |
*In cases of true PCOS, women may not present with all symptoms.
How to Diagnose Pill-Induced PCOS
In a woman with absent periods after stopping the pill, lasting at least 3-4 months, here is how to diagnose pill-induced PCOS:
Clinical features:
- No menstruation for at least 3 months after stopping oral contraceptives.
- Acne – mild to moderate.
Lab testing:
- High LH to FSH ratio – typically 3:1 ratio or more (although the diagnosis is still considered in any case of LH > FSH).
- Fasting insulin level is normal, meaning < 60 pmol/L or < 10 uIU/mL.
- Possibly polycystic ovaries seen on pelvic ultrasound.
Treatment of Pill-Induced PCOS
The good news with a diagnosis of pill-induced PCOS, is that once your menstrual cycle returns and you start to ovulate regularly, the other signs and symptoms of PCOS are likely to resolve for good.
In my own practice, and for many of my colleagues the supplement that works best to bring back ovulation and regular menstruation with pill-induced PCOS is a herbal combination of licorice root and white peony. This is particularly helpful in cases of high LH levels (luteinizing hormone). Licorice and peony supplements are typically continued for 3-4 months, until periods are regular and then the herbs can be stopped. One important note is that licorice root is contraindicated if you have high blood pressure or high cortisol levels. Also, do not use the popular herb Vitex if LH is high, as it may aggravate your symptoms rather than help to bring back menstruation (Vitex is very helpful for many other types of hormone imbalance).
Additional factors to consider:
- Stress: Chronically high stress levels tend to amplify any hormone imbalance, including pill-induced PCOS. This is often an obstacle that will stall your progress.
- Nutrition: Eating sufficient calories is essential for regular ovulation and menstruation, as is a balanced nutrition plan. Remember that any type of crash dieting, excessive fasting, or calorie restrictin can stop ovulation and will prevent your period from returning too.
- Exercise: Regular, moderate exercise is optimal for hormone balance. Over-exercising can affect ovulation and hormone balance, so caution with taking on an overly aggressive exercise plan while you are working on getting your period back on track.
I truly hope that this short article has been helpful to clarify the diagnosis of this ‘temporary’ form of PCOS – it can be a very rewarding condition to treat.
What’s Next?
If you’ve been diagnosed with PCOS, or have been doing your own research and suspect you might, I hope this article provides some insight to you, especially if it might be temporary.
Book an appointment with Dr. Darou online.
Contact us: 416.214.9251, admin@drdarou.com
www.darouwellness.com
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