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Polycystic Ovarian Syndrome (PCOS)

Updated: Dec 3, 2022

Summary: PCOS is a hormone disorder affecting women of all ages typically beginning in the teenage years. Females with PCOS often exhibit irregular periods, acne, excess hair growth on face, legs, and back, excess belly fat, and difficulty becoming pregnant. A nutrient dense/low glycemic diet, along with targeted supplements and an exercise routine can reduce symptoms dramatically.



Polycystic Ovarian Syndrome (PCOS)

The most common endocrine disorder in reproductive-aged women, PCOS typically appears at the onset of puberty. It has an estimated prevalence between 5 and 10%. (Rosenfield, Barnes & Ehrmann 2016) PCOS is a complex of heritable traits whose interaction with other congenital issues (including ethnic origin and race) or environmental conditions is inconsistent because these factors can modify the expression of the PCOS phenotype. It seems likely that the condition is under-diagnosed. (Ring 2018) First described by Stein and Leventhal in 1935, PCOS was defined initially by the observation of atypical numbers of cysts in the ovaries of a subset of women. The condition has been studied by many researchers during the intervening 85 years and it is understood that most of those affected exhibit atypical menses and / or infertility. It is also associated with serious general health issues that extend far beyond the recognition of ovarian cysts and an abnormal uterine milieu. Women with PCOS suffer external clinical signs that include obesity, acne and hirsutism. Internally, these individuals are at increased risk for developing diabetes mellitus, heart disease, and other health issues. (Patel 2018)


Pathogenesis

The cause of PCOS is unknown. (Rosenfield, Barnes & Ehrmann 2016) The vast majority (60-80%) of patients have functional ovarian hyperandrogenism. Excess androgens hinder ovulation and cause the development of the anatomic features of polycystic ovaries. About two-thirds of women with PCOS are insulin resistant. (Rosenfield, Barnes & Ehrmann 2016) Insulin resistance exerts negative effects on the ovaries, pituitary, hypothalamus, and possibly the adrenal glands. (Ring 2018)


Dysfunction of the hypothalamic-pituitary axis may lead to gonadotropin-releasing hormone (GnRH) and luteinizing hormone (LH) dysfunction which alter the amount of each ovarian hormone synthesized. (Ring 2018)


Ovarian hyperandrogenism has local effects on the reproductive system and its control. Hyperandrogenism also has systemic effects on metabolism. Locally, androgens stimulate pituitary LH secretion which paradoxically enhances hyperandrogenism from the ovary. In addition, hyperandrogenism leads to varying expression of hirsutism, acne, anovulation and polycystic ovaries. Systemically, ovarian hyperandrogenism contributes to insulin-resistance and obesity. When all these factors are appreciated, individual variance in presentation should be expected. (Rosenfield, Barnes & Ehrmann 2016)


Diagnostic Criteria

Conference Consensus Statements


Three independent international conferences have issued criteria for the diagnosis of PCOS based on various combinations of otherwise unexplained abnormalities: a) clinical and biochemical evidence for hyperandrogenism; b) evidence of anovulation; and c) presence of polycystic ovaries (ovaries with too many small fluid-filled structures). The Rotterdam criteria, most broad and encompassing, list 4 phenotypes in order of decreasing frequency. Phenotype I is considered “classic” and includes women with issues a, b, and c. Phenotype 2 includes those with a and b; phenotype 3 includes women with a and c, while phenotype 4 includes women with b and c. These definitions should be further refined by health care professionals. Criteria must be adapted to gynecologic age for application to adolescents in view of their high prevalence of physiologic anovulation and oligomenorrhea. (Rosenfield, Barnes, & Ehrmann 2016)


Diagnostic Testing

History and physical examination should focus on symptoms and signs, such as oligomenorrhea, acne, hirsutism, and central obesity, as well as searching for manifestations of any other concurrent disease. (Ring 2018) Testing often includes pelvic ultrasound for ovarian assessment, androgen levels (dehydroepiandrosterone (DHEA) sulfate), and total and free testosterone (measured by equilibrium dialysis). Testing to rule out alternative diagnoses are employed as indicated. These include congenital adrenal hyperplasia, androgen-secreting tumors, Cushing syndrome, 21 hydroxylase-deficient non-classic adrenal hyperplasia, androgenic or anabolic drug use or abuse, syndromes of severe insulin resistance, thyroid dysfunction, and hyperprolactinemia. Laboratory testing for anti mullerian hormone is a diagnostic tool that, in combination with LH concentrations, has been shown to have sensitivity and specificity in diagnosing PCOS. (Ring 2018)


Treatment

Pharmaceuticals

Pharmaceutical treatments for PCOS include insulin sensitizers such as Metformin and Orlistat, hormone modulators such as progestins, antiandrogens (spironolactone), oral contraceptives, IUDs and clomiphene citrate as well as weight loss medications.


Bariatric surgery has been effective for morbidly obese individuals.


Integrative Therapy

Lifestyle choices have been shown to minimize symptoms and are considered sustainable therapies for PCOS (Patel 2018). Considering each woman’s unique issues is critical for success. A thorough history is important for diagnosis.


Physical activity improves insulin resistance and lean body mass. The optimal exercise regimen for PCOS has not been established, so finding an enjoyable activity will encourage long-term sustainability. A study in Human Reproduction compared the effects of a low-calorie diet versus exercise. Exercise gave better results with higher ovulation rates, smaller waist measurements and improved insulin sensitivity. (Ring 2018)


Weight Management plays a critical role in the symptoms and long-term effects of PCOS. It is reported that up to 70% of women with PCOS are obese. Reducing their weight buy 5-10% has shown to have significant improvements in symptoms. (Ring 2018) Weight loss is known to improve insulin sensitivity in all obese individuals.


Nutrition. The ideal diet for PCOS patients continues to evolve but recommendations are trending towards low-carbohydrate, low-glycemic index, and high-fiber. (Ring 2018). Avoid estrogen-mimicking chemicals found in herbicides, pesticides, and bovine growth hormones (watch dairy products). Eating an anti-inflammatory diet filled with nutritious foods low in simple sugars can help heal the body and improve insulin sensitivity.


A diet rich in organic, non-GMO vegetables (low starch) such as asparagus, artichoke, avocado, broccoli, cabbage, cauliflower, celery, cucumber, eggplant, leafy greens, mushrooms, peppers, tomatoes, onions, squash and turnips will provide vitamins, minerals, fiber and phytonutrients. Organic grass-fed meats, pasture raised chicken and eggs and wild-caught fish will build lean body mass, neurotransmitters and other important tissues. Remove all inflammatory processed seed oils and replace with cold-pressed avocado and olive oil. Eat grass-fed organic dairy and use coconut or avocado oil to cook with. Eat soaked and sprouted legumes, seeds and nuts. These healthy foods will help stabilize blood sugar. By limiting simple sugars and processed foods, blood sugar spikes will be avoided and requirements for insulin decreased. Drink filtered water to avert other endocrine disrupting chemicals in tap water.


Supplements


In several studies using D-chiro-inositol (DCI), improvement was seen in insulin sensitivity, triglycerides, and testosterone levels as well as blood pressure, ovulation and weight loss. For clients under 130lbs, 600mg daily, or 1200mg daily for those over 130lb. (Ring 2018)


Omega-3 Fatty Acids may assist managing the inflammatory component of PCOS as well as supporting cardiovascular health. Ground flaxseeds may also be beneficial in assisting estrogen elimination. (Ring 2018)


Chromium is an essential dietary agent that potentiates the action of insulin and thereby functions in regulating carbohydrate metabolism. Chromium deficiency may lead to impaired glucose tolerance, leading to reduced control of blood sugar in people with type 2 diabetes. Food sources for chromium are broccoli, liver, brewer’s yeast, potatoes, whole grains, seafood, and meat. Unfortunately, little research has been done on patients with PCOS. (Ring 2018)


Vitamin D plays a role in glucose regulation. In a small study with women who had PCOS and vitamin D deficiency, after two months of vitamin D repletion with calcium therapy, normal menstrual cycles resumed. 2000 units daily or more based on serum levels. (Ring 2018)


Botanicals

Cinnamomum cassia has been shown to reduce insulin resistance. Published in the July 2007 issue of Fertility and Sterility, taking 1⁄4 to 1⁄2 teaspoon daily reduced insulin resistance in women with PCOS.


Licorice root has antiandrogen effects that may support treatment for PCOS. It has been associated with reduced serum testosterone and ovulation induction in women with PCOS. 500mg daily (Ring 2018)


Chaste Tree Berry (Vitex) One of the most popular botanicals for PCOS, though lacking in well-conducted studies, Vitex is believed to shift the estrogen- progesterone balance in favor of progesterone. 30-40 mg of dried fruit extract daily or 40 drops of tincture. (Ring 2018)


Complementary Healing Approaches


Stress reduction

Biochemical imbalances from altered androgen levels or insulin resistance may cause mood disorders such as depression and anxiety in women with PCOS. Mind-body therapies can help women manage stress, depression and anxiety related to PCOS. Cognitive-behavioral therapy and self-care should be encouraged. Yoga, meditation, Emotional Freedom Technique and time spent in nature can relieve stress and promote well-being.


Acupuncture has limited research, but one study showed women who received electro acupuncture treatments had more regular menstrual cycles, reduced testosterone levels and reduced waist circumference. (Ring 2018)


References:

Medling, A. (2018) Healing PCOS, HarperCollins Publishers, 195 Broadway, New York, NY (Pp. 300)

Oiu, Z., Dong, J., Xue, C., Li, X., Liu, K., Liu, B., Cheng, J., Huang, F. (2019) “Liuwei Dihuang Pills alleviate the polycystic ovary syndrome with improved insulin sensitivity through P13K/Akt signaling pathway” Journal of Ethnopharmacology, 2020 Mar 25;250:111965. DOI: 10.1016/j.jep.2019.111965


Patel, S. (2018) Polycystic ovary syndrome (PCOS) an inflammatory, systemic, lifestyle endocrinopathy. Journal of Steroid Biochemistry Mol Biol 2018 Sep;182:27-36. DOI:10.1016/j.jsbmb.2018.04.008


Ring, M. (2018) Polycystic Ovarian Syndrome, in Rakel’s Integrative Medicine (4th edition Pp. 361-369). Elsevier, Philadelphia


Rosenfield, R., Barnes, R., Ehrmann, D. A. (2016) Hyperandrogenism, Hirsutism, and Polycystic Ovary Syndrome, in Jameson & De Groot’s 7th edition of Endocrinology Adult and Pediatric (Volume 11 Pp. 2275-2296). Elsevier, Philadelphia, PA

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