A gluten-free (GF) diet for PCOS is a very popular (and contentious) topic on social media right now. And then here’s you, trying to wade through all of the conflicting advice, because you just want to feel better and need to know what’s going to work for you! Am I right?
As with ANYTHING in nutrition, there is nuance to explore and that’s what this article intends to do. After reading, you’ll have a good idea of whether or not a gluten-free diet is something you should consider.
Spoiler alert: Cutting gluten out of your diet isn’t a question of “Do you have PCOS?”, but rather, “Do you have an issue with gluten?”
What is gluten?
Gluten is the collective term for particular storage proteins found in the grains- wheat, rye, and barley. Wheat contains the proteins glutenin and gliadin, secalin in rye and hordein in barley. (1)
In baking, gluten acts as a binder, providing elasticity and lends to the chewy texture of things like bread.
Common sources of gluten:
Wheat products:
- Pastas
- Noodles
- Flour tortillas
- Bread
- Baked goods
- Bread crumbs
- Croutons
- Cereal, some granola
- Flour
- Crackers
- Some candy
- Sauces, gravies and soups
- Soy sauce
Barley products
- Malt
- Beer
- Brewer’s yeast
- Cereal
- Soups
Rye products
- Bread
- Beer
- Rye flour
- Cereal
Due to its thickening and emulsifying qualities, it is often added to many food products that may be less obvious sources like imitation crab, seasonings, marinades, dressings, and ice cream.
Gluten is also used in some medications and supplements as filler or coating and in personal care products.
What foods don’t have gluten?
Naturally, gluten-free foods include:
- animal proteins- chicken, beef, pork, fish, shellfish
- Butter and oils
- Dairy products
- Eggs
- Fruits and vegetables
- Gluten-free grains like quinoa, teff, rice, amaranth, GF oats, millet, buckwheat, corn
- Beans, legumes, nuts, seeds
Processed foods can be produced and labeled as gluten-free, such as gluten-free crackers made with alternative flours. A certified gluten-free product means that the producer has met strict standards to avoid cross-contamination and the end product was tested for gluten.
Who may benefit from a gluten-free diet?
Let’s walk through the health conditions in which a gluten-free diet may be necessary or potentially beneficial.
Celiac disease
Celiac disease, also known as non-tropical sprue, is a serious autoimmune disease in which the immune system attacks the lining of the small intestine in response to gluten exposure. It is estimated to affect 1% of the population (2).
Symptoms can present as intestinal or extra-intestinal (outside the gastrointestinal system or GI tract). Common GI symptoms are bloating, diarrhea, nausea, vomiting, and abdominal pain.
Extra intestinal symptoms can present as weight loss, neurologic issues, skin issues, iron-deficiency anemia, nutrient deficiencies and more.
Destruction of the absorptive surface of the small intestine leads to malabsorption of nutrients and potentially many of the downstream effects nutrient deficiencies may cause.
Blood markers are usually run first, but the gold standard for diagnosis is intestinal biopsy via endoscopy (scope down the esophagus). Gluten must be in the diet prior to any testing to avoid a false negative result.
A strict gluten-free diet is imperative and currently the only treatment for this disease. Great care must be taken to minimize cross contamination (for example, separate toasters for GF and regular bread).
Wheat allergy
There is no such thing as a gluten allergy, but it is possible to have an allergy to one of the gluten-containing grains, wheat. It is more common in children. (2)
A wheat allergy is an overreaction of the immune system, in which the body produces IgE antibodies upon ingestion or inhalation of wheat which stimulates release of histamine.
Symptoms are usually mild and occur immediately. They can include wheezing, hives or skin rash, stuffy/runny nose, sneezing, headaches, asthma, or gastrointestinal symptoms like indigestion, vomiting, or diarrhea.
In severe cases, wheat can cause a sudden and life threatening condition called anaphylaxis that can result in serious symptoms like difficulty breathing, a dangerous decrease in blood pressure, disruption in heart rhythm and swelling of the airway.
For those with severe wheat allergy, it is necessary to carry an epinephrine injection with them at all times in the case of accidental ingestion, to reverse the life-threatening symptoms of anaphylaxis.
Wheat allergy is diagnosed with blood test, skin-prick test or medically-supervised oral food challenge.
Managing wheat allergy requires a wheat-free diet. Treatments can include use of antihistamines or epinephrine, if needed.
Non-celiac gluten sensitivity
Non-celiac gluten sensitivity (NCGS) is diagnosed upon exclusion of celiac disease and wheat allergy, but is more challenging as we currently lack a diagnostic marker to test. It is more commonly found in adult women than men (4).
Symptoms can be gastrointestinal in nature; most commonly bloating, diarrhea, abdominal pain, nausea, and reflux. But, extra-intestinal symptoms like headache/migraine, brain fog, fatigue, skin rashes, eczema, joint pain, depression, anxiety, fibromyalgia and neuropathy can also be experienced (5).
Sensitivity to gluten can be difficult to single out, as symptoms can appear up to days after ingestion.
The current evidence suggests that NCGS is a result of intestinal inflammation, microbiome dysbiosis and a disruption in the intestinal barrier. This break in the intestinal barrier, allows movement of dietary proteins and microbes into the bloodstream which triggers a response in the immune system (6)
An interesting connection is that patients with NCGS are more frequently diagnosed with autoimmune diseases, in particular Hashimoto’s thyroiditis (7). Further, women with PCOS have been shown to have an increased risk of Hashimoto’s.
Currently, the suggested criteria for identifying NCGS is gluten elimination for 6 weeks followed by a gluten challenge while careful, continuous assessment of symptoms throughout the process.
Basically, if you feel better on a gluten-free diet, and symptoms return upon adding gluten back into your diet, you will be diagnosed with NCGS.
Treatment is a gluten-free diet.
Other conditions
Hashimoto’s thyroiditis
Hashimoto’s thyroiditis (HT) is an autoimmune disease that causes hypothyroidism. In this condition, the body’s own immune system attacks the thyroid gland, leading to eventual dysfunction of the gland.
As mentioned, an increased incidence of Hashimoto’s has been shown in those with non-celiac gluten sensitivity.
There are some small studies that have demonstrated improvements in symptoms with a gluten-free diet, but overall the research does not yet support it as a broad recommendation for HT (8).
In practice, I have seen enough patients with HT that have had improvements in their symptoms on a gluten-free diet, that I generally do at some point recommend a 4-6 week trial off of gluten in those that are willing.
It is worth noting that women with PCOS have been found to be more likely to develop Hashimoto’s, although the mechanism or link has yet to be discovered. Thus, screening for HT in all women with PCOS is encouraged (9, 10).
Fructans/FODMAPS
Fructans are a type of FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides and polyols) which are poorly digested carbohydrates.
FODMAPS draw water into the bowel and in some can cause symptoms like bloating and diarrhea (11). They can also be fermented (or eaten) by bacteria in the gut, which produce gases as a byproduct, which can lead to gas, bloating and other digestive symptoms.
Wheat, rye and barley are a significant source of fructans, a high FODMAP food, so removing these gluten-containing foods can result in digestive relief if you have an issue.
So in some, relief may come from removing or limiting fructans (a type of carbohydrates) and not necessarily from the removal of gluten (a type of protein). Often issues with FODMAPS involve intestinal dysbiosis, or when the microbial environment in the gut is out of balance (12).
In this case, a low FODMAP diet may be helpful as it removes foods that are higher in FODMAPS, like fructans.
Please note, the low-FODMAP diet is not recommended long-term and should be used under the guidance of a registered dietitian.
Can a gluten-free diet help PCOS?
Now you know the conditions that a gluten-free diet may benefit, but what about PCOS?
PCOS is a condition of low-grade inflammation, so if you do have an issue with gluten involving the immune system, removing it may decrease inflammation and thus result in an improvement in PCOS in some cases.
But, as it stands today, there is no existing evidence in the scientific literature that has demonstrated a link between gluten and PCOS or that a gluten-free diet should be a broad recommendation for PCOS management.
Removing gluten from your diet is not a question of “Do you have PCOS?”, but rather a question of, “Do you have an issue with gluten/wheat?”
Maybe you’ve already tried a GF diet and have noticed improvements. Here are some potential reasons why:
- You have undiagnosed celiac disease or wheat allergy
- You have a true gluten sensitivity and removing it decreased immune response/inflammation in the body
- In removing gluten, you by default removed sources of refined carbohydrates and sugars (cookies, crackers, etc.) & started eating more whole foods & experience the benefit of this shift in dietary pattern
- You actually have an issue with fructans
Should you try it?
You know your body better than anyone on planet earth and if you have a suspicion that gluten may be affecting you and want to try a gluten-free diet, I’m behind you all the way.
The best plan in that case is to completely avoid gluten for 4-8 weeks to see how you feel, then reintroduce it, all the while carefully recording symptom changes through the process. This is where working with a dietitian can be helpful.
Now, Is a gluten-free diet going to be the silver bullet that magically fixes all your PCOS problems? No.
And that’s what I don’t like about the message some people are sending- that the key to successful management of PCOS requires a gluten-free diet for every single person with the syndrome.
Some of my clients DO need to remove gluten as a part of their healing, but what you may find surprising, is that I very rarely will start with it. In the beginning, I’d rather see my clients adopt an additive, instead of a restrictive, mindset when it comes to food and learn the basics of integrating gentle nutrition in a sustainable way.
So many of you have already been there with diets. For once, I’d like you to focus on what you are adding to your plate instead of what you are taking away. As a dietitian, I also carefully consider the other issues that contribute to why and how you eat, and if gluten-free is really the most important at the moment.
Please note: Eating disorders are more prevalent in women with PCOS, so if you have a history of an eating disorder or disordered eating, this may do more harm than good.
So, what will help my PCOS?
So often, when we are looking for answers for our health we want to zoom in on one cause or one food we need to eliminate and the truth is, it’s usually never that simple.
PCOS is a complex syndrome affecting many different systems in the body, with many contributing factors. And although nutrition is foundational to manage the condition, it should be highly personalized.
If you’re feeling lost and wondering where to start, focus on some of the basics of PCOS support:
- Incorporate more fresh anti-inflammatory fruits and vegetables
- increase healthy fats like olive oil, nuts, seeds and avocados
- Include adequate and quality protein at every meal and snack
- cook more meals at home
- Increase water intake and limit sugary drinks
- balance foods on your plate to support stable blood sugar
- Get consistent restful sleep
- Manage stress
- Move your body daily in a sustainable way
- Work on your gut health
- Make sure you understand your root causes of symptoms by getting the right labs
If you need some personalized support , check out my, one-on-one PCOS Pro program.
I will also be launching the PCOS Pro Academy online course in 2023. Join my mailing list, as I will be sharing a pre-sale discount with my audience.
Closing thoughts
In your search to find nutrition help for PCOS you will likely at some point encounter advice to adopt a gluten-free diet.
A gluten-free (and in some cases, wheat-free) diet is a legitimate treatment for multiple health conditions that can have major benefits.
As of today, there is no evidence that a GF diet should be a broad recommendation in PCOS, so beware of anyone making this claim. You have to be so careful when consuming any type of PCOS nutrition content on the internet or social media.
Be skeptical of anyone speaking in extremes or stating everyone with PCOS needs to remove a particular type of food, especially when they don’t have adequate studies and research to back it up.
If you feel that gluten may be affecting you, you can always do an elimination for 4-6 weeks to see if you note changes.
Questions? Comment below or reach out on Instagram @pcos.pro.dietitian.
Tara