POLYCYSTIC OVARY SYNDROME (PCOS)
Definition
PCOS is a complex condition that is located in the
reproductive system, involves the endocrine system,
but is primarily a metabolic condition. The term
polycystic refers to the appearance of many small
cysts on the ovaries when examined by ultrasound.
These ‘cysts’ are actually undeveloped follicles
and will appear on approximately 20% of all
ovarian ultrasounds. Presence of these cysts is
diagnosed as polycystic ovaries (PCO), which differs from
PCOS in that the latter condition includes hormonal and metabolic
abnormalities. Of the women diagnosed
with PCO only about 7-8% will have PCOS, although 80% of women that do not
ovulate regularly will have PCOS. 1
It is estimated that between 5-10% of women have PCOS. Many women will start to experience menstrual
irregularities 3-4 years after menarche, with most cases being diagnosed at the
age group of 20-29. 11
Aetiology
It is thought that the primary cause of PCOS is insulin
resistance and chronic hyperinsulinaemia which lead to ovarian and adrenal
hyperandrogenism. Insulin resistance can
be acquired or amplified due to central obesity, a sedentary lifestyle, smoking
or corticosteroid use. 1 Oestrogen
dominance is also a significant causative factor, and may occur due to the
following reasons:
-
Increased activity of the ovarian enzyme cytochrome P450c17α which is responsible for forming androgens in both the ovaries and adrenal glands. 2
-
Stress and low blood sugar levels (BSLs) → release of ACTH (adrenocorticotropic hormone) from the pituitary which stimulates the adrenal glands to produce elevated levels of DHEA (dehydroepiandrosterone), an androgen which is converted into oestrone (a type of oestrogen). 2
-
Excess weight has been shown to increase the rate of aromatisation in fatty tissue – that is the conversion of androgens into oestrone. 3 The levels of the carrier protein for oestrogen and testosterone, SHBG (sex hormone binding globulin) are also reduced in obese women, resulting in increased circulation of these hormones. 1
-
Adrenal or hypothalamic-pituitary dysfunction can cause inappropriate stimulation of hormones that are able to increase the level oestrogen in the body. 3
-
Imbalance of oestrogen relative to progesterone.
Women with a family history of PCOS have a 40% chance of
developing the condition, clearly illustrating a genetic link. 3
The hormone leptin which is secreted by adipocytes is
responsible for the regulation of body weight by its effect on metabolism,
satiety and energy metabolism. The
presence of leptin receptors on ovarian follicles indicates that this hormone
is also involved in the regulation of follicular development. In obese women the levels of leptin are
greatly increased, this may cause leptin resistance and lead to persistently
high levels of LH (luteinising hormone), which is a significant factor in PCOS.1
Pathophysiology
Before looking at the Pathophysiology, let’s first have a
quick review of normal physiology. Firstly,
there are two main oestrogens in the body: Oestradiol and Oestrone.
Oestradiol is low during the follicular phase and high during
the luteal phase due to ovulation. Anovulation results in decreased levels of oestradiol.
Oestrone is primarily derived from the peripheral conversion
of androgens in fat and muscle tissue in a process called aromatisation. Increased body fat increases the level of
oestrone. Irregular menstruation also
increases oestrone levels. 1
To limit confusion, I will just refer to oestrogen in
general. The female reproductive cycle
typically lasts from 24-35days and is divided into four phases (based on a 28
day cycle):
1. Menstrual phase – lasts for
about 5 days, is the shedding of the endometrium. The hypothalamus secretes GnRH (gonadotropin
releasing hormone) → pituitary releases FSH (follicle stimulating hormone) →
follicular growth in the ovary is initiated.
2. Follicular or pre-ovulatory
phase, days 6-13 – FSH is still high, the follicles continue to grow and begin
to secrete oestrogen which stimulates growth of the endometrium. One dominant follicle continues to develop
and the others undergo atrophy, FSH levels decline and oestrogen rises due to stimulation
from LH.
3. Ovulation, day 14 – the mature
oocyte is released into the pelvic cavity. There is a dramatic drop in FSH levels and a gradual decline in LH.
4. Luteal or postovulatory phase,
day 15-28 – LH causes the corpus luteum to secrete progesterone and oestrogen, other
hormones such as prolactin are also released during this phase. As the endometrium prepares for embryo
development the level of progesterone increases, and LH continues to slowly
decrease. If the oocyte is not
fertilised then the levels of progesterone and oestrogen will decrease,
stimulating the release of FSH and LH. Follicular growth begins again and the endometrium will shed (menses). 1,
4
Hyperinsulinaemia increases the production of androgens in
the ovaries by stimulating the secretion of LH, by directly stimulating ovarian
tissue or by indirectly enhancing the adrenal production of androgens. 1
A high androgen environment alters the hypothalamic release
of GnRH and increases the sensitivity of the pituitary to GnRH. This causes an increase in the secretion of
LH while at the same time inhibiting FSH . This means that the new follicles cannot fully mature and ovulation can
not occur and no corpus luteum develops. 5 The lack of corpus luteum means that
progesterone levels do not increase as they normally would, this results in the
absence of negative feed back to the hypothalamus-pituitary unit and results in
persistent acyclic oestrogens . Once
again LH comes into play, as it becomes chronically elevated it stimulates the
production of more ovarian androgens. 1 Chronic anovulation results in amenorrhea and
an oestrogen environment, eventually causing bilaterally enlarged ovaries. 5
High oestrogen levels during the luteal phase stimulate
prolactin, because oestrogen levels do not drop as they would in a normal cycle
this causes abnormal negative feedback mechanism whereby prolactin continues to
be secreted. High levels of prolactin
then further stimulate the release of more oestrogen. Approximately 25% of women with PCOS have
elevated prolactin levels. 1, 2
Essentially, the reproductive cycle of a woman with PCOS has
the following alterations:
Menstrual phase – FSH is inhibited, follicular growth is
still initiated.
1. Follicular phase – FSH
inhibition means that no dominant follicle will develop and mature. LH is high which increases the level of
oestrogen.
2. Ovulation – No mature follicle
means there is no ovulation. LH levels
continue to be elevated, which keeps increasing the levels of oestrogen.
3. Luteal phase – No ovulation
means that no corpus luteum develops, therefore progesterone is not secreted. Continued elevated LH levels means that
oestrogen is still secreted leading to excessive levels of oestrogen in
relation to progesterone. Lack of
fertilisation would normally inhibit oestrogen, however, as there is no oocyte
present, the level of oestrogen does not drop as it normally would. The high levels of oestrogen inhibit
FSH. Menstruation may or may not occur.
Clinical manifestations
♀ Secondary amenorrhoea or oligomenorrhoea will be
experienced in 90% of cases.
50% of women will
not menstruate.
♀ Hyperinsulinaemia occurs in 90% of cases, regardless of the
woman’s weight.
♀ Ultrasounds will show multiple ovarian follicles in between
65-85% of PCOS
women.
♀ Infertility or recurrent miscarriages will affect 75% of
these women.
♀ Hirsutism – excess body hair and/or androgenic alopecia
will affect 50-60% of
Women.
♀ Obesity is observed in 40% of cases. 3 Women with PCOS have significantly lower
Postprandial
thermogenesis which means that they store fat more efficiently and burn
calories more
slowly, making weight loss very difficult. 6
♀ Adult acne occurs in 40% of cases.
♀ Abnormal bleeding patterns have been recorded in 30% of
cases.
♀ Hyperprolacinaemia occurs in 25% of women with PCOS.
♀ Only 15% of women with PCOS will be experiencing ovular
cycles if they are
menstruating. 3
♀ Acanthosis nigricans – this refers to the thickening and
pigmentation of the skin,
these lesions can
be found on the vulva, nape of the neck, inner thigh and below the
breast. They are caused by severe insulin resistance.2
Excess levels of androgens are the cause of most of these
manifestations – such as acne, hirsutism, androgenic alopecia and menstrual
irregularities. Reduced levels of SHBG
caused by increased androgens, insulin resistance and obesity increase the
level of unbound active androgens (primarily testosterone) in the body. 1 The presence and activity of androgens on the
skin are responsible for hirsutism. 2
Excess weight can make many of the symptoms associated with
PCOS more pronounced, particularly menstrual irregularities, infertility and
hirsutism. Increased fatty tissue in the
body allows for the increased aromatisation of androgens into oestrone. Excess abdominal weight in both obese and
non-obese women with PCOS contributes to insulin resistance. 1
Further to the above manifestations, these women are at an
increased risk of developing type II diabetes, high cholesterol, hypertension,
cardiovascular disease, endometriosis, endometrial cancer, eating
disorders. If these women are able to
conceive, they have a much higher risk of miscarriage before 14 weeks gestation.6
Treatment - Allopathic
The first step of orthodox treatment is to get a definitive
diagnosis. This is done by ruling out
other endocrine disorders that present with a similar picture and then checking
to see if the woman has several of the above mentioned symptoms. 3
Treatment protocols involve addressing each prominent symptom
as well as managing the associated risks, such as high blood pressure, high
cholesterol and diabetes as mentioned earlier. 7
Medications for regulating
the menstrual cycle.
- Oral contraceptive pill (OCP),
if pregnancy is not a current goal then a low dose is used to decrease androgen
production and relieve the body of the effects of continuous oestrogen. This option also decreases the risk of
endometrial cancer and regulates abnormal bleeding.
- Metformin, this is primarily
used to moderate insulin resistance, but recent research has shown that it
improves ovulation and reduces androgen levels. 3, 7
Medications for reducing
hirsutism
- OCP is also used for this
reason as it decreases androgen production.
- Spironolactone (Aldactone) is
used to block the effect of androgens and to reduce androgen production. This drug is also a diuretic and may cause
headaches, fatigue and heartburn.
- Cyproterone acetate,
Finasteride (Propecia, Proscar) and flutamide (Eulexin) are other
anti-androgenic medications used for this condition.
- Electrolysis and laser therapy
are also recommended for the long term removal of unwanted hair. 3, 7
- OCP
- Spironolactone 7
-
Medications for insulin
resistance
- Metformin has a significant
effect in reducing fasting insulin levels, blood pressure and LDL cholesterol. 3
Medications to improve
ovulation and fertility
- Clomiphene (Clomid, Serophene)
is an anti-oestrogen medication used to trigger ovulation.
- Metformin can be taken with
Clomiphene to stimulate ovulation when Clomiphene alone does not work.
- Gonadotropins – FSH and LH
intra-venous medications may be used if the first two medications are
ineffective.
- Surgery – if none of the above
medications improve fertility, then laparoscopic ovarian drilling may be
recommended. Through small incisions in
the abdomen a laser is used to burn holes in the enlarged follicles on the
surface of the ovaries. The goal is to
trigger ovulation by decreasing the levels of LH and androgens – but doctors
are not sure exactly how this occurs. 7
Allopathic treatment protocols also include daily exercise,
increasing complex carbohydrates and fibre and decreasing simple carbohydrates
and counselling or support groups. 7
Therapeutic considerations – Diet
Naturopathic treatment considerations follow the same goals
as allopathic in that the diagnosis must be clearly made first, and that the
relief of symptoms is very important as is reducing the risk for the
development of other conditions. An
overall balancing of hormones is the key standout point naturopathically.
A good diet can do much to alleviate many problems associated with PCOS; the following 8 principles will be of benefit in many ways, particularly in blood sugar management and in the balancing of hormones:
1. Water
Drink at least 1.5L/day. This aids in eliminating wastes and by making the fibre in food swell
and move through the gastrointestinal tract (GIT). Water is also important to support liver
function – which enhances the breakdown and elimination of toxins. 6
2. 5+ a day
Eating 5+ a day of different coloured fresh fruit and
vegetables will ensure there are plenty of antioxidants, vitamins, minerals,
phytochemicals and fibre in the diet. 6
3. Low GI (glycaemic index) foods
Complex carbohydrates should make up approximately 50% of the
diet; this will prevent fluctuating BSL and reduce the amount of insulin that
needs to be secreted. Apples, pears,
peaches, plums, cherries, green leafy vegetables, lentils, legumes, nuts, whole
grains and whole foods in general are all tasty low GI foods. 6
4. High fibre between 30-50g/day
Both soluble and insoluble sources are important. Soluble fibre slows the conversion of foods
into glucose and also binds to excess cholesterol and oestrogens, helping to
remove them from the body. Insoluble
fibre keeps the GIT moving which prevents the build up of hormones and toxins
in the gut. Fibre in general may assist
with weight loss by stabilising BSL and promoting satiety. It also has the added benefit of reducing
cardiovascular diseases (CVDs). Good
sources include whole grains, nuts, seeds, fruit, vegetables, seaweed, psyllium
hulls and slippery elm powders. It is
important to increase fibre slowly in order to give the bowels time to adapt. 6
5. Good quality protein with every meal
This will help to regulate BSL, provide amino acids for
hormone production and increase muscle mass which will help with weight loss as
more calories are able to be burnt. It
is important to eat a good mix of both animal and vegetable proteins (if you
are not vegan/vegetarian), it is best to minimise the amount of animal
protein. Approximately 0.75g of protein
per kg of weight is recommended, this can be adjusted to meet activity levels
and general lifestyle requirements.
Good sources of quality protein include beans, lentils, tofu,
organic dairy, organic lean meat/poultry, organic eggs, nuts and seeds. 6
6. Phytoestrogens
These wonderful plant chemicals help to balance excess
oestrogen by binding to oestrogen receptors in a process called competitive
inhibition. While phytoestrogens exert an
oestrogenic effect, it is much weaker than endogenous oestrogen. Good sources of phytoestrogens include
legumes, soy products, tofu and linseeds. 3
7. Essential Fatty Acids (EFAs)
Up to 25% of daily calories should be from good fats such as cold pressed (or
virgin) vegetable oils, oily fish, nuts, seeds, LSA and fish oil supplements. EFAs help to regulate hormone function,
improve skin and hair, regulate menstruation and BSL. 6
8. Eat regular small meals
Eating 5-6 meals daily will help to stabilise BSL, increase
metabolic rate and energy levels, all of which will also assist in weight loss.6
There are also some foods that should be avoided:
-
Caffeine, alcohol and refined sugary foods – these trigger the release of insulin. Alcohol also exerts an oestrogen like effect, interferes with the absorption of many micronutrients, puts a strain on the liver and contributes to weight gain. 6
-
Saturated fatty acids and highly refined food are involved in the production of androgens. 6
-
Junk food, fast food and highly refined carbohydrates contribute to oestrogen dominance. 6
-
Xenoestrogens from non-organic meat, poultry and dairy (these are also found in plastic containers and plastic wrap). 6
Therapeutic considerations – Nutritional supplements
The below are specific nutrients that along with the above
dietary guidelines will assist in the treatment of PCOS.
B Vitamins, especially B6– the B’s are essential for the healthy function of the liver
and for proper digestion and absorption. B6 helps with acne, depression, insulin resistance, hormonal
imbalance and irregular or absent periods. Supplement form: 50mg B6 as
part of a B vitamin complex. 6
Chromium - improves glucose tolerance, increases the binding of
insulin to cells by increasing the number of insulin receptors and activating
insulin receptor kinase, thereby increasing insulin sensitivity. 1 Chromium
has also been found to maintain levels of HDL cholesterol and to assist in
weight loss. Supplement form: 300mcg daily
of chromium picolinate or chromium amino acid chelate. 6
Vitamin E – this powerful antioxidant helps to balance BSL, improve
skin and hair and plays a role in supporting menstrual regularity and
fertility. Supplement form: 30mg daily
of d-alpha-tocopherol. 6
Folic acid – deficiency may be associated with reproductive failures and
skin disorders, among many other conditions. This vitamin is essential for women who want to conceive as it
facilitates the differentiation of embryonic nervous tissue (deficiency has
been linked with spina bifida). Folic
acid has also been used successfully in the treatment of acne and menstrual
irregularities. Supplement form: 1000mcg
daily. 8
Magnesium – deficiency of this mineral has been associated with PMS
and diabetes and a clear link between magnesium deficiency and insulin
resistance has also been observed. Supplement form: 300mg daily of magnesium amino acid chelate or
magnesium citrate. 6
Zinc – This mineral is integral in the synthesis, storage and
secretion of insulin, deficiency of zinc can inhibit the production and
secretion of insulin. Zinc is also an
antioxidant, assists with fertility and a healthy reproductive cycle as well as
being the key mineral in the treatment of acne. Supplement form: 75mg daily of Zinc amino acid
chelate or Zinc sulphate – this amount is equivalent to about 15mg of elemental
zinc. 6
Because many of the above micronutrients require a variety of
synergistic nutrients to optimise their absorption it is advisable to find a
good women’s multivitamin supplement. Some of the micronutrients may still require additional supplementation
depending on the levels in the multi. There are also a number of products specifically designed to regulate
BSLs such as Metagenics Resist-X. This particular product contains a variety of
herbs, B vitamins, Chromium and Zinc and may be another way of obtaining the
above important micronutrients.
Therapeutic considerations – Lifestyle
Obtaining and maintaining ideal body weight is really
important in the long term management of PCOS. Losing weight, if necessary will help to reduce insulin levels, which in
turn will reduce the ovarian production of testosterone; also, when there are
less fat cells the level of aromatisation will decrease and the number of SHBG
proteins will increase. 6
Regular exercise that increases the heart rate will help with
weight loss, reduce the risk of CVD and increase the amount of SHBG. 1
Detoxifying the liver to encourage efficient metabolism and
elimination of hormones and toxins is also important. 6
Take time to indulge in a scalp massage using thyme,
lavender, cedar wood and a carrier oil such as almond oil. This will help if androgenic alopecia is a
problem. 6
Come off the OCP. The
OCP can cause a deficiency of many micronutrients, particularly the B vitamins,
vitamins C and E and Zinc. It has also
been shown to affect insulin metabolism. 6
Alleviate stress!!! Stress triggers the release of insulin
and the secretion of testosterone from the adrenal glands and can eventually
cause insulin resistance, weight gain, depression, irregular periods and high
blood pressure. 6
Summary: by eating a balanced healthy diet using the above
guidelines and by undertaking the lifestyle recommendations, insulin levels
will decrease, androgen and oestrogen levels will decrease,
oestrogen/progesterone ratio will become more balanced, menstrual cycles and
ovulation will start to become regular and fertility will improve. As these are the underlying factors of PCOS,
the resulting symptoms and potential complications will also be greatly
reduced.
Herbal treatments
Herbs can be very useful in the treatment of PCOS. The main aims are to manage BSLs, balance
hormones and support the liver. While
there are many herbs that will help with this, the following appeared most
prominently in my research:
-
Vitex agnus-castus: this herb is very well known for its hormone balancing capability. It has been shown to reduce excess prolactin and androgens, thereby promoting normal luteal phases and increasing progesterone levels. Vitex is more effective when it is used in conjunction with Tribulus and Paeonia
-
Glycyrrhiza glabra: this versatile herb is important for supporting adrenal function, reducing testosterone levels and initiating ovulation. It is also useful in the treatment of hirsutism and may be of assistance in weight loss. 2, 3, 9
-
Paeonia lactiflora: has a positive influence on progesterone, reduces elevated androgens and modulates oestrogen and prolactin. In vitro it has been shown to assist in follicular maturation and corpus luteum function, thereby initiating ovulation and improving fertility. It is also useful in the treatment of hirsutism. 2, 3
-
Gymnema sylvestre: this is the primary insulin modulating herb, it has traditionally been used to lower BSL and lipid levels and also assist in weight loss by reducing carbohydrate/sugar cravings. 2, 3
-
Schisandra chinensis: is a great liver herb that improves the livers ability to conjugate sex hormones, thereby reducing the circulating levels of testosterone and oestrogen. 2, 3
-
Tribulus terrestris: this is an oestrogen and androgen modulator and as such it has been used to restore menstrual regularity, initiate ovulation, normalise follicle development and to improve fertility. 2, 3
Psycho-social and metaphysical factors
Conditions involving the ovaries are related to the inability to express or accept ones own creativity. 10
A woman with PCOS may feel
powerless as the vicious cycle of hormonal imbalances creates severe symptoms,
which in turn fuel and worsen the hormonal imbalances. Being advised to ‘simply lose weight’ as if
she hadn’t thought of that and tried at various points can make this woman feel
very frustrated. The excess body hair,
loss of scalp hair, anovulation and resulting infertility can make this woman
feel as though she has lost her femininity. Low self esteem and depression are likely to be experienced.
References
1 Trickey, R. (2003), Women, Hormones & The Menstrual Cycle: Herbal and medical solutions from adolescence to menopause, 2nd ed, Allen & Unwin, Crows Nest, NSW
2 Hywood, A & Bone, K. (2004, November), “Phytotherapy for Polycystic Ovarian Syndrome (PCOS)”, A Phytotherapist’s Perspective, no. 46
3 Bulloch, S. (2004), “Phytotherapy for Polycystic Ovarian Syndrome”, Modern Phytotherapist, vol. 8, no. 2
4 Tortora, G
and Grabowski, S (Ed) (2003) Principles
of Anatomy and Physiology, 10th Edition, John Wiley & Sons
Inc., New York
5 Porth, C. (2005), Pathophysiology: Concepts of
6 Harris, C. (2002), PCOS Diet Book: How you can use the nutritional approach to deal with
polycystic ovary syndrome, Thorsons,
7 “Polycystic Ovary Syndrome” (2005, August 4), (Mayo Clinic), Available: http://www.mayoclinic.com/health/polycystic-ovary-syndrome/DS00423 (Accessed: 2006, October 10)
8 Osiecki, H. (2002), The Nutrient Bible, 5th ed, Bioconcepts, Eagle Farm, QLD
9 Morgan, M. (2005, February), “Herbal Treatment of Polycystic Ovary Syndrome: Focus on Hyperandrogenism & Anovulation”, A Phytotherapist’s Perspective, no. 49
10 Pagans Path, Available: http://www.paganspath.com/healing/ailments.htm (Accessed: 2006, October
21)
11 NZ PCOS Support, Available: http://www.nzpcos.org/forum/faq.php?faq=welcome#faq_whoisaffected
(Accessed: 2006, October 21)
