Categories: Diseases & Treatment Plans

Polycystic Ovarian Syndrome (PCOS)

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
Treatment
Best Therapeutic Treatment
Referral for:
  • Hormone panel
  • Free Testosterone
  • Total Testosterone
  • SHBG
  • Fasting glucose
  • HbA1c
  • Insulin
  • Ultrasound
Dietary
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
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
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
Abbott, D. H., Dumesic, D. A., Eisner, J. R., Colman, R. J., & Kemnitz, J. W. (1998). Insights into the development of polycystic ovary syndrome (PCOS) from studies of prenatally androgenized female rhesus monkeys. Trends in endocrinology and metabolism: TEM, 9(2), 62–67. https://doi.org/10.1016/s1043-2760(98)00019-8
Bani Mohammad, M., & Majdi Seghinsara, A. (2017). Polycystic Ovary Syndrome (PCOS), Diagnostic Criteria, and AMH. Asian Pacific journal of cancer prevention : APJCP, 18(1), 17–21. https://doi.org/10.22034/APJCP.2017.18.1.17
Barr, S., Reeves, S., Sharp, K., & Jeanes, Y. M. (2013). An isocaloric low glycemic index diet improves insulin sensitivity in women with polycystic ovary syndrome. Journal of the Academy of Nutrition and Dietetics, 113(11), 1523–1531. https://doi.org/10.1016/j.jand.2013.06.347
Bone, K. (2007). The Ultimate Herbal Compendium. Phytotherapy Press
Braun, L., & Cohen, M. (2015). Herbs and Natural Supplements, Volume 2. Elsevier Health Sciences.
Hechtman, L. (2018). Clinical Naturopathic Medicine. Elsevier Health Sciences.
Kataoka, J., Tassone, E. C., Misso, M., Joham, A. E., Stener-Victorin, E., Teede, H., & Moran, L. J. (2017). Weight Management Interventions in Women with and without PCOS: A Systematic Review. Nutrients, 9(9), 996. https://doi.org/10.3390/nu9090996
Lee, W. J., Song, K. H., Koh, E. H., Won, J. C., Kim, H. S., Park, H. S., Kim, M. S., Kim, S. W., Lee, K. U., & Park, J. Y. (2005). Alpha-lipoic acid increases insulin sensitivity by activating AMPK in skeletal muscle. Biochemical and biophysical research communications, 332(3), 885–891. https://doi.org/10.1016/j.bbrc.2005.05.035
Marshall, J. C., & Dunaif, A. (2012). Should all women with PCOS be treated for insulin resistance?. Fertility and sterility, 97(1), 18–22. https://doi.org/10.1016/j.fertnstert.2011.11.036
Ndefo, U. A., Eaton, A., & Green, M. R. (2013). Polycystic ovary syndrome: a review of treatment options with a focus on pharmacological approaches. P & T : a peer-reviewed journal for formulary management, 38(6), 336–355.
Sheehan M. T. (2004). Polycystic ovarian syndrome: diagnosis and management. Clinical medicine & research, 2(1), 13–27. https://doi.org/10.3121/cmr.2.1.13
Unfer, V., Facchinetti, F., Orrù, B., Giordani, B., & Nestler, J. (2017). Myo-inositol effects in women with PCOS: a meta-analysis of randomized controlled trials. Endocrine connections, 6(8), 647–658. https://doi.org/10.1530/EC-17-0243
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