Recommended treatment for PCOS and endometriosis?


What can you do about cravings during your cycle? How can you best lose weight if you have hypothyroidism? What treatment do you recommend to PCOS and endometriosis? And, can keto help with menstrual pain?

Get the answers to these questions in this week’s Q&A with fertility specialist Dr. Fox:

Cycle help

Dr. Fox,

Thank you for your time and expertise. I am 43 years old, was diagnosed with PCOS when trying to conceive 15 years ago. Had four children—twins after IVF and two without IVF. I am 5’7” (170 cm) and weigh 146 pounds (66 kilos) with BMI around 23. I feel great when I weigh around 135 pounds (61 kilos), so trying to lose around 10 pounds (5 kilos).

I have been in ketosis for ten weeks and have had three menstrual cycles while in ketosis (average length around 23 days—with ovulation usually between days 9-11). During the 7-10 days leading to my period, I have outrageously strong food cravings—have literally had dreams that I am eating a tray of cupcakes. I also experience night sweats during the week prior to menstruation and regularly gain 8-10 pounds of water weight during this time. My body feels pretty miserable, but the extremely low mood I also used to experience during this week is gone since starting keto, so that is a huge win!

While I have not caved into eating carbs during the cravings, I feel intensely driven to eat during this premenstrual week only and any pounds I have lost during the other days of my cycle get put back on.

Each cycle I feel pretty awful from day 16 (cravings hit me like a truck) to day six (water gained has finally left my body and I feel like myself again). So I have about nine days or less each month where I feel like a healthy, normal person, and about 14 where I feel pretty awful.

I have checked my fasting blood sugar and blood ketones every morning for the past ten weeks and have not dropped below 1.0 mmol/L and no blood sugars above 100. During the nine or so days that I feel really good, morning blood ketones are around 2.0-3.0 mmol/L with blood glucose in the 70s. Closer to my period ketones get closer to 1.0 and blood sugars get into the 90s.

Any advice or insight that might help me have more good days than bad? I feel like my period derails my life and my progress and that it is coming so frequently now I am having trouble keeping my head above water! Thank you again for your time.


Dr. Fox:

Sorry you are struggling. Your history is indicative of low estrogen and the lowest point is the week leading up to and during the first few days of your cycle. I would suggest estrogen supplementation and I bet you will find much of the life disruption will dissipate. Your symptoms are a good example of estrogen deficiency. That is not written anywhere but hopefully you can get with your doctor and have them put you on estrogen supplementation.

Good luck.


Autoimmune hypothyroidism

Hi, I have hypothyroidism and I’ve been doing the 2-week keto challenge. I lost some pounds but it’s really difficult for me to lose weight; what would you recommend me to change or to do to lose more pounds?


Dr. Fox:

In two weeks we would only be looking for a max of 4 pounds (2 kilos) of weight loss. Often people gain dense lean body mass that offsets the fat loss early on. Be patient and give it time. Keep up the good work.

Good Luck.


Recommended treatment for PCOS and endometriosis

Hi Dr. Fox,

So my husband and I have been trying to get pregnant for over six years now. I have endometriosis, probably PCOS or hypothalamic dysfunction and probably low estrogen according to your responses to other women. I’m 29 years old, 5’2” (157 cm) and 123 pounds (56 kilos). I had laser surgery for the endometriosis five years ago with no reduction for pain. I remember seeing all of the cysts on the ultrasound and I can feel the pain on my sides sometimes throughout my cycle. No one ever told me I may have PCOS/hypothalamic dysfunction, but I have also noticed hirsutism and my cycles are monthly, but never average out (anywhere from 26-35 day cycles). I am unable to make it through a cycle without ibuprofen for menstrual pain. Tylenol doesn’t touch the pain.

I read on your website that you recommend laparoscopic excision for endometriosis rather than the laser treatment. Do you think that LAPEX surgery, keto diet and estrogen supplementation would be a good route for me to look into? As you said, many doctors aren’t offering the same support as you’ve recommended. I was always told that my cycles and levels were “normal” and pregnancy would happen any month now (that was five years ago). Can you recommend a blood test list of what to test and normal ranges for estrogen/androgen/etc that I can request from my local ob/gyn?

Honestly, we aren’t crazy about IVF and we felt like we had exhausted our options and were ready to forget fertility and grow our family through adoption instead, but after reading what you have to say about endometriosis and PCOS treatment I am wondering if there are still treatments other than IVF (surgery/supplements/lifestyle changes) that may be worth pursuing. Have you seen women with my host of issues get pregnant after this long without IVF?

Thank you for your thoughts.

Dr. Fox:

Yes for sure. As you cross thirty though, the chances are less, but your three-year pregnancy rate is at least 40%. By history though you will probably need a little fertility medicine to help you ovulate better. Your plan as listed sounds great. Estrogen levels won’t help and we don’t measure them but simply rely on symptoms. Checking testosterone would be confirmatory and rule out a very rare androgen-secreting tumor.

Good Luck.


Menstrual pain and LCHF

My 33-year old daughter, who eats the standard American diet, has menstrual cramps severe enough to require hormone replacement therapy (HRT). She was recently diagnosed with an inferior vena cava clot and has had to discontinue the HRT, leaving her with severe cyclical pain. I do not know of a formal diagnosis for the menstrual pain, but she is lean, fertile and in otherwise excellent health. Is there any evidence that an LCHF diet might improve her severe monthly menstrual pain?


Dr. Fox:

Based on your description, she most likely has endometriosis and adenomyosis. I have had many patients who pursued ketogenic nutrition tell me their pain improved. Surgery to excise the endometriosis and cut the uterine nerve would also be very effective. Excision needs to be the method used at the surgery to relieve pain. This technique is not found in many places in the U.S. Both approaches would be very helpful.
Good Luck.


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