Polycystic Ovarian Syndrome (PCOS)

Published by NHC on January 5, 2021January 5, 2021

Polycystic Ovarian Syndrome (PCOS)

Info
Description	A hormonal disorder affecting the ovaries with characteristics of menstrual dysfunction, hyperandrogenism, and polycystic ovaries
Signs & Symptoms	Anovulation (amenorrhea, oligomenorrhea) Hyperandrogenism Polycystic ovaries Hirsutism (in approximately 60% of PCOS cases) Acne Infertility Menstrual abnormalities Often menarche at age 12-13 and never develop a consistent pattern of regular menses. Alopecia/hair loss Recurrent miscarriages Obesity (often wth central adiposity) (40-60%) Insulin resistance (40-80%) Elevated hormones Androgens Luteinsing hormone (LH) Oestrogen Prolactin Increased LH/FSH ratio of greater than 2:1 (60-70% of PCOS cases) More likely to occur in the non-obese Lipid abnormalities Increased risk of impaired glucose tolerance (IGT) Type 2 diabetes
Causes & Contributors	Excess of androgens Insulin resistance Obesity Genetic factors Always get family history of PCOS, Diabetes, Excess hair growth, Irregular menstrual cycles, Acne, Difficulty becoming pregnant. Impaired stress response (HPA dysfunction) Post-pill hormonal imbalance Inflammatory conditions
Pathophysiology/Aetiology	Main issue is excess androgen secretion/activity. A large proportion of women with PCOS also have insulin resistance Polycystic ovaries have a thickened thecal layer, these secrete excessive androgens in response to LH Insulin resistance may contribute to hyperandrogenism and gonadotrophin abnormalities. High concentrations of insulin decrease SHBG, therefore increasing testosterone. First signs of PCOS may be early development of pubic hair. Increased weight reduces insulin sensitivity, can increase androgens, and reduces ovulation.
Commonly Affected	Approximately 1 in 7 women worldwide Women of reproductive age
Complications	Infertility Type 2 diabetes Increased risk of Metabolic syndrome
Treatment
Best Therapeutic Treatment	Referral for: Hormone panel Free Testosterone Total Testosterone SHBG Fasting glucose HbA1c Insulin Ultrasound Dietary Limit carbohydrates Low GI/GL (Glycaemic Index/Glycemic Load) Diet Consume These: Low GI diet Spearmint tea (especially during follicular phase) Has been shown to have anti-androgenic effects Cinnamon Blood sugar regulation Flaxseed oil For ALA Blood sugar regulation Avoid These: Refined carbohydrates White bread Pasta Cakes/cookies Potatoes (use sweet potato instead) Sugar Alcohol Caffeine Numerous studies show caffeine impairs fertility Nutrition Inositol 4g + 400mcg folic acid/day Lifestyle Exercise Daily walking Anything to increase physical movement (eg. walking instead of driving, taking the stairs) Reduce stress Meditation Yoga Walking Something to clear the mind Example Herbal Mix (May change depending on pathology test results and/or clinical symptoms) Gymnema sylvestre 1:1 80ml Paeonia lactiflora 1:2 70ml Glycyrrhiza glabra STD ext. 30ml Vitex agnus-castus 1:2 40ml
Goals	Weight loss/Healthy weight Reduce insulin resistance Stabilise blood sugar, avoid fluctuations.
Herbal	Cimicafuga racemosa (Black Cohosh) Reduces LH (high LH is a characteristic of PCOS) Modulates androgens Cinnomomon spp (Cinnamon) Improves insulin resistance Glycyrrhiza glabra (Liquorice) Antiandrogenic Gymnema slyvestre Improves insulin resistance Paeonia lactiflora (Peony) Increases low progesterone Reduces elevated androgens (testosterone) Modulates oestrogen and prolactin Clinical evidence in combination with liquorice including increased fertility, decreased testosterone, reduction in LH:FSH levels, increased conception. Phytolacca decandra May help with ovarian pain and infection by facilitating waste removal (cysts). Schisandra chinensis Works on phase 1 and 2 liver detoxification. Helps aid clearance of sex hormones Tribulis terrestris May be used to increase FSH which will in turn lower LH:FSH ratio Vitex agnus-castus Regulates HPO axis Reduces prolactin Increases progesterone Example Herbal Mix (May change depending on pathology test results and/or clinical symptoms) Gymnema sylvestre 1:1 80ml Paeonia lactiflora 1:2 70ml Glycyrrhiza glabra STD ext. 30ml Vitex agnus-castus 1:2 40ml
Nutritional	B complex Metabolism of carbohydrates Reduce homocysteine associated with metformin use Reduce lipids, cholesterol, triglycerides Chromium Improve insulin sensitivity Magnesium Found to be low in PCOS patients Deficiency is a proposed underlying factor in PCOS Controlled release ALA Shown to improve insulin sensitivity by 13.5% and lower triglycerides Zinc May help insulin sensitivity Acne improvement Inositol One study shows induced ovulation in 62% in PCOS patients when taken in combination with 400mcg folic acid/day
Dietary	Limit carbohydrates Low GI/GL Diet Eat These: Low GI diet Spearmint tea (especially during follicular phase) has been shown to have anti-androgenic effects Avoid These: Refined carbohydrates White bread Pasta Cakes/cookies Potatoes (use sweet potato instead) Sugar Alcohol Caffeine Numerous studies show caffeine impairs fertility *Give food swap ideas if necessary
Lifestyle	Weight loss Set achievable goals Just 2-5% weight reduction has massive improvements on PCOS Small reduction in weight helps restore ovulation and increase insulin sensitivity by up to 71% in obese anovulatory women Increases SHBG, reduces testosterone, improves menstrual function, improves conception rates and decreases miscarriage rates. Exercise Daily walking Anything to increase physical movement (eg. walking instead of driving, taking the stairs) Reduce stress Meditation Yoga Walking Something to clear the mind
	OCP Cyproterone acetate Antiandrogen medication Often combined with OCP Laser electrolysis Hirsutism Eflornithine cream Hirsutism Spironolactone Hirsutism Metformin Insulin resistance Thiazolidinediones & D-chiro-inositol are better for inducing ovulation Minoxidil Androgenic alopecia Clomiphene citrate Inducing ovulation Gonadotrophin therapy Ovarian drilling
More
Differential Diagnosis	PCOD (used as diagnosis when there is ultrasound evidence of cysts) Congenital adrenal hyperplasia Cushing’s syndrome Androgen-secreting tumours Hyperandrogenism Raised prolactin (Hyperprolactinaemia) Insufficient follicle stimulating hormone (FSH) for ovulation
Diagnostic Criteria	Rotterdam (2003) Criteria: (2 out of 3 required) Oligo- or anovulation Clinical and/or biochemical signs of hyperandrogenism Polycystic ovaries on ultrasound *Exclusion of other aetiologies
Testing/Examinations	Clinical features Look for hirsutism Look for balding Look for presence of acne Ultrasound Hormone panel LH, FSH, oestradiol, progesterone, prolactin, BHCG Free and bound testosterone, free androgen index (FAI), SHBG, DHEA-S, Androstenedione Metabolic profile Fasting GTT, insulin, fasting glucose, Hba1C Lipid profile Triglycerides, HDL, LDL, vLDL, total cholesterol, Apo lipoproteins, lipoproteins Thyroid panel TSH, T3, T4, reverse T3, Thyroid antibodies, urinary iodine, spot iodine 2 and 16 urinary oestrogen metabolite measures the metabolised pathways of oestrogen ratio should be 2.0 between 2:16 pathways
Additional Notes	Administration of dihyrdotestosterone to female rhesus monkeys induces a polycystic ovary-like condition.
Images/Infographics

References

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