Adrenal PCOS: Holistic Strategies to Manage Stress and PCOS

As many as 30% of those diagnosed with polycystic ovary syndrome (PCOS) have elevated levels of DHEA-S due to adrenal androgen excess. PCOS is one of the most common endocrine disorders affecting women, with some estimates stating up to 70% of women remain undiagnosed¹.

Adrenal PCOS Symptoms include:

Irregular menstrual cycles
Hirsutism (unwanted, excess hair growth on the face and body)
Acne
Weight gain
Hair loss
Mood symptoms, like anxiety or depression
Infertility (PCOS is the leading cause of infertility related to lack of ovulation)

In addition, upwards of 70% of those with PCOS struggle with insulin sensitivity. This can result in symptoms of high testosterone, like acne and oily skin, as well as weight gain.

However, many women live with undiagnosed PCOS because they don't fit the “picture” of how PCOS is conventionally understood. In recent years, research has highlighted the importance of adrenal function in PCOS development and highlights the importance of testing for DHEA-S as part of the evaluation.

What Is Adrenal PCOS?

Adrenal PCOS is a type of PCOS in which the adrenal gland produce excess androgens (DHEA-s), contributing to acne, infertility, and hair loss. While the ovaries are typically the primary source of elevated androgen levels in PCOS, about 20-30% of PCOS patients² have increased adrenal androgen secretion.

In cases of adrenal PCOS, these patients benefit from modification of adrenal hormones³, in addition to ovarian hormones and insulin.

What are The Adrenal Glands?

The adrenal glands are two small glands that sit on top of each kidney and are responsible for the production of cortisol, DHEA, epinephrine, norepinephrine, and aldosterone. In cases of adrenal androgen excess, DHEA-S levels are elevated.

Adrenal androgen production can be measured via DHEA-S in the blood.

Adrenal health includes the optimal functioning of the adrenal glands, along with the hypothalamic-pituitary-adrenal (HPA) axis. The HPA axis⁴ regulates hormones involved in the stress response and reproductive function.

For most PCOS cases, high levels of androgens⁵ contribute to irregular periods, acne, hair loss, facial hair, and other symptoms. Let's look at PCOS more closely first.

What Causes Adrenal PCOS?

Adrenal PCOS is characterized by an overproduction of androgens from the adrenal glands. The exact cause is not well understood, but currently there are several factors that may contribute:

Genetics: While not clear, there may be a genetic predisposition to developing adrenal PCOS.
Insulin resistance: Insulin and blood sugar dysregulation can contribute to symptoms of adrenal PCOS.
Chronic stress: Long Term stress can contribute to HPA dysregulation, commonly referred to as adrenal fatigue. PCOS and adrenal fatigue are two conditions that are often linked.

What is the Difference Between PCOS and Adrenal PCOS

The primary difference between PCOS and adrenal PCOS is the source of androgen production. In adrenal PCOS, the adrenal glands, not just the ovaries, are contributing to the production of androgens.

Types of Androgens and Where They are Produced:

Dehydroepiandrosterone sulfate (DHEAS) – produced in the adrenal gland
Dehydroepiandrosterone (DHEA) – produced by the adrenal gland (50%), ovaries (20%), and converted from circulating DHEAS
Androstenedione – produced by the adrenal gland and ovary
Testosterone (T) – produced by the adrenal glands and ovary
Dihydrotestosterone (DHT) – converted from circulating testosterone by the enzyme 5-alpha reductase with a very small amount coming from the ovaries

The ovaries and adrenals⁶ can both synthesize androgens, so for those with adrenal PCOS, upregulation of the stress response adds to the problem.

How Do I Know If I Have Adrenal PCOS

The Rotterdam Criteria can be used to diagnose PCOS, in addition to testing DHEA-S, cortisol, and in some cases adrenocorticotropic hormone or ACTH (a pituitary hormone) to assess adrenal involvement.

The Rotterdam Criteria specifies that you need to have 2 out of the 3 following symptoms:

Polycystic ovarian morphology
Elevated levels of androgens (can be a clinical diagnosis)
Anovulatory cycles (results in irregular periods)

In all suspected cases of PCOS, adrenal conditions such as Cushing's syndrome and non-classical congenital adrenal hyperplasia (NCAH) need to be ruled out⁷.

Your doctor may also test anti-mullerian hormone (AMH), which is often elevated in cases of PCOS. You can learn more about AMH and PCOS here.

Adrenal PCOS is not an official medical diagnosis, but it is a term used to describe the relationship of stress on hormone balance and PCOS.

In some case, adrenal PCOS is associated with:

Overexercise
Low body fat
Significant weight loss
Sleep disruptions
Chronic calorie restriction
High-stress levels

If you have these lifestyle factors and are experiencing symptoms of PCOS, it's worth talking to your healthcare provider about the possibility of adrenal PCOS. A thorough evaluation can help identify the root cause of your PCOS and create a personalized treatment plan.

Connection Between PCOS and Stress

PCOS patients are more likely to experience anxiety and depression. The physical changes associated with the condition, along with infertility and hormone imbalance further exacerbate the stress associated with PCOS.

You may have heard the phrase “adrenal fatigue,” often associated with stress. HPA axis dysregulation⁸ is the scientifically accurate term to describe what is happening within the endocrine system following prolonged periods of stress.

When the body is under chronic stress, the adrenal glands can produce high levels of cortisol (the primary stress hormone). This prolonged cortisol production can eventually lead to dysregulation of adrenal function by way brain communication to the adrenal glands. In some instances, enzymes are upregulated to inactivate cortisol and in others, the receptors can be less receptive to the cortisol signal.

Stress can worse PCOS symptoms by:

Increase DHEA production and androgen levels
Elevating blood glucose levels
Exacerbating insulin resistance
Disrupting ovulation, leading to anovulatory cycles
Decrease production of progesterone
Increase production of adrenal hormones that can contribute to anxiety

Stress can show up differently in each of us and the body can't always differentiate between physical and emotional stress.

Stressors that can causes changes to our hormones include:

a toxic work environment
chronic inflammation
irregular sleep patterns
anxiety
over exercising
under eating

Many women with PCOS have been told to exercise more and eat less and unfortunately, that advice can worsen adrenal PCOS.

How Stress Affects Hormone Levels in PCOS

In many women with PCOS chronic stress can lead to androgen excess originating from the adrenals⁹.

In response to stress, the brain produces ACTH¹⁰, which is a hormones that stimulates the adrenals to produce hormones like cortisol or adrenaline that regulate the stress response and reproduction.

In response to ACTH, the adrenals also produce DHEA and DHEA-S—precursors to testosterone and the main circulating androgens for females. Almost all the DHEA-S¹¹ in your body comes from the adrenals.

Research¹² suggests that DHEA is a biomarker of acute stress and that women may have a higher response. There's some indication that DHEA may be protective for the brain under chronic stress.

Stress Management and PCOS

It's now recognized that lifestyle changes should be the first line of treatment¹³ for PCOS, including stress management. By addressing stress you can also manage common symptoms of PCOS.

I'm all too aware that simply telling you to manage stress isn't exactly helpful. My goal is to make you more stress-resilient because we can't realistically remove all the stressors in life, but you can develop strategies that limit the impact on your body.

Sleep Support

Lack of sleep can contribute to inflammation, anovulatory cycles, insulin resistance¹⁴ and increased cortisol production, and worsening symptoms. Sleep is where your adrenal glands are given a chance to recover, which is why it is top of the list as a priority.

I know that telling you to sleep more isn't always helpful, so sometimes natural sleep support or calming herbs like lemon balm, passionflower, and valerian can aid in getting more restful sleep. Magnesium¹⁵ can also be a helpful tool for relaxation and sleep support.

Mind-Body Therapies for Stress Relief

Numerous studies¹⁶ have highlighted the potential benefits of mind-body therapies in supporting stress relief and improving overall well-being.

Some techniques you may want to try include:

progressive muscle relaxation
deep breathing exercises
mindfulness meditation
yoga

These techniques can decrease anxiety, improve mood, and reduce stress levels in women with PCOS. For more stress reduction techniques to support our hormones, I invite you to read this article.

Supplements for Adrenal PCOS Support

When elevated androgens from the ovaries and adrenals are an issue, looking at supplements that can support the function of these glands can provide benefits in addition to nutrition and lifestyle therapies.

Adaptogenic herbs such as Rhodiola, Holy Basil and Ashwaghandha can help support a healthy cortisol response. Look for a blend that also provides necessary nutrients for adrenal function like vitamin C and pantothenic acid. You'll find these in the Dr. Brighten Essentials Adrenal Support.
Myo-inositol and d-chiro-inositol have been shown¹⁷ to improve insulin sensitivity and support regular menstrual cycles. In addition to an ideal balance of myo-inositol to d-chiro-inositol, I’ve included nutrients like chromium and spearmint to support healthy androgen levels in the Myoinositol Plus formula.
Saw palmetto is an herb that has been shown to be beneficial in helping the body regulate the potent androgen behind irreversible hair loss and acne.

The PCOS Plus Kit provides the primary evidence backed nutrients and herbs to support adrenal PCOS.

Before starting any supplements, it is important to consult with a healthcare provider to determine the appropriate dosages and ensure they won't interact with any other medications you may be taking.

Balancing Blood Sugar Levels

Blood sugar balance is intimately connected with adrenal health. Imbalances in blood sugar are one type of stressor that can result in worsening of adrenal PCOS symptoms.

Eating a nutrient dense diet with emphasis on quality protein and fiber is an important aspect of managing blood sugar and PCOS symptoms. You can download my free recipe guide to learn how to start incorporating foods that support both adrenal health and PCOS hormones here.

Exercise and Its Role in Stress Management

Exercise helps elevate your mood, reduces stress, and has a positive impact on hormones. But they type of exercise does matter when you’re recovering from HPA dysregulation or adrenal PCOS.

While there are people who will tell you that you should never engage in high-intensity interval training (HIIT) if you have PCOS, this isn't entirely true. If you’re currently working to balance DHEA-S, cortisol, and testosterone then the best type of exercise to focus on is:

Strength training
Walking
Swimming
Yoga
Pilates

Or any activities that do not push you into maximum output. The best way to gauge this is to exercise at a level where you can still hold a conversation (but not easily) while working out. If you’re unable to talk while you’re exercising, you’re definitely in a higher stressed state.

In addition, rest days are essential in not only achieving your fitness goals, but also allowing your hormones to recalibrate.

This is what it will look like during a healing phase. But this is not what it will look like for your entire life. As you take steps to recover, your intensity and type of exercise will shift too.

In general, a training routine for adrenal PCOS may look like:

Weight lifting 3-4 days a week
Walking 5,000-10,000 steps daily
Yoga 1-2 days a week
Stretching daily

Managing Adrenal PCOS by Addressing the PCOS and Stress Connection

It can feel overwhelming to start, but I want you to know that adrenal PCOS is absolutely treatable. Small steps to address the root cause of your stress are an essential starting point. If it's physical, as seen with undernutrition or overexercise, it may make sense to work with someone to help you relearn to be kind to your body again, whether it's a mental health professional, dietitian, or another healthcare practitioner who understands the connection.

If the stress is emotional, I understand you can't always make that go away, but you can use the tools mentioned above to find moments of calm in the chaos.

By addressing stress with adrenal PCOS, you can limit its impact on your symptoms, support your overall long-term health, and just feel good in your body again.

References

About The Author

Dr. Jolene Brighten

Dr. Jolene Brighten, NMD, is a women’s hormone expert and prominent leader in women’s medicine. As a licensed naturopathic physician who is board certified in naturopathic endocrinology, she takes an integrative approach in her clinical practice. A fierce patient advocate and completely dedicated to uncovering the root cause of hormonal imbalances, Dr. Brighten empowers women worldwide to take control of their health and their hormones. She is the best selling author of Beyond the Pill and Healing Your Body Naturally After Childbirth. Dr. Brighten is an international speaker, clinical educator, medical advisor within the tech community, and considered a leading authority on women’s health. She is a member of the MindBodyGreen Collective and a faculty member for the American Academy of Anti Aging Medicine. Her work has been featured in the New York Post, Forbes, Cosmopolitan, Huffington Post, Bustle, The Guardian, Sports Illustrated, Elle, and ABC News. Read more about me here.

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