Polycystic ovarian syndrome

Polycystic ovarian syndrome (PCOS) is one of the most common causes of infertility in women, affecting approximately 5% of the female population. This complex disorder of the endocrine system develops when either high levels of insulin are present in the blood, or excessive amounts of LH are released from the pituitary gland thus stimulating the ovaries to produce excessive levels of androgens (male hormones). Because of this ovarian dysfunction, follicular development becomes arrested at an early stage, producing ovulatory disturbance and the characteristic appearance of multiple ovarian cysts (immature follicles) on ultrasound. PCOS is strongly correlated with diabetes, insulin resistance, and obesity, although its cause is not definitely known. PCOS is defined by the Rotterdam criteria as presenting with two out of the three following; polycystic ovaries on ultrasound, excessive androgenic hormones, and anovulation or oligoovulation (irregular or absent ovulation).

Chinese Medicine treatment of PCOS

In the 1990s a European study was conducted on anovulatory women with PCOS. The results indicated that the use of electro-acupuncture was effective in restoring ovulation in 33% of the test subjects. This study also showed an improvement in many of the endocrine indicators of PCOS, including follicle size, luteinizing hormone (LH), follicle-stimulating hormone (FSH), and mean testosterone levels.

Chinese medicine, acupuncture, herbs, dietary and nutritional therapy, and reproductive organ massage are effective in managing the complex pattern of symptoms found in PCOS and slowing the progression of the disorder. By promoting optimal functioning of the endocrine and reproductive systems, fertility is restored for women who wish to become pregnant. There are a number of different treatment options that are prescribed depending on the specific presentation involved for each patient:

Acupuncture can be used to stimulate ovulation and regulate the menstrual cycle as well as improve fertility and regulate blood flow to the ovaries thus improving egg quality and follicle size. Due to acupuncture’s effect on the endocrine system, it can also be used to help normalize the hormonal disorder present in PCOS.

Herbal formulas are prescribed to help the body regulate overall hormone levels, including insulin, testosterone, estrogen, progesterone, LH and FSH. When started early they may slow the progression of the disorder. Anti-inflammatory herbs are often used, since PCOS has a strong inflammatory component.

Massage and physical therapy can prevent and attempt to correct the waxy capsule formed around the ovaries in PCOS. It is also useful to increase blood flow to the reproductive system.

Nutritional and dietary therapy is used to improve insulin resistance and keep blood sugar levels steady. Certain foods may also regulate estrogen and progesterone balance, as well as decrease excessive testosterone levels. Where PCOS is associated with excess weight or obesity, weight loss is a key component in restoring normal ovulation and menstruation. Diet and exercise programs tailored to the individual are used to achieve long-term weight control.

The nutritional supplement D-chiro-inositol has been evaluated in two peer-reviewed double-blind studies, and has been shown to improve many of the primary clinical presentations of PCOS.

Avoiding products containing xenoestrogens is important, because they can increase the growth of ovarian cysts.

Coffee, alcohol and recreational drug use can impact liver clearance of estrogen and make symptoms worse.

Possible causes of polycystic ovarian syndrome

PCOS is characterized by a complex set of symptoms, and for most patients a direct cause is not known. Current research seems to point to insulin resistance as a leading cause of the abnormalities seen in the hypothalamic-pituitary-ovarian axis that lead to PCOS. This theory is also supported by the fact that the majority of PCOS patients have insulin resistance, whether they are overweight or not. The hyperinsulinemia found in many PCOS patients is associated with altered LH/FSH ratios, decreased follicular maturation, increased gonadotropin-releasing hormone (GnRH) pulse frequency, decreased sex hormone–binding globulin (SHBG), and increased ovarian androgen production all of which are considered precursors of PCOS.

PCOS may also have a genetic predisposition, and while no specific gene has yet been identified, further research to identify a gene or a group of genes is taking place.

Chronic inflammation may also play a role in the development of PCOS. Research suggests a strong correlation between inflammatory mediators and anovulation and other common symptoms of PCOS.

Symptoms of polycystic ovarian syndrome

PCOS can present at any age during the reproductive years and is often misdiagnosed due to its varied presentation. There is a wide range of severity of symptoms among women. Common symptoms of PCOS include:

  • Oligomenorrhea, amenorrhea — irregular, few, or absent menstrual periods
  • Infertility, generally resulting from chronic anovulation (lack of ovulation)
  • Hirsutism — excessive and increased body hair, typically in a male pattern affecting face,
  • chest and legs
  • Prolonged premenstrual syndrome (PMS) symptoms such as bloating, pelvic pain,
  • breast tenderness and changes in mood
  • Hair loss, appearing as thinning hair on the top of the head
  • Acne, oily skin, seborrhea
  • Obesity — one in two women with PCOS are obese
  • Depression or mood swings
  • Skin tags, i.e. small pieces of excess skin in armpit or neck area
  • Abnormal levels of insulin or insulin resistance
  • Polycystic ovaries or enlarged ovaries containing more than twelve follicles
  • Headaches
  • Hyperprolactinemia (excessive levels of the hormone prolactin)
  • Darkening of skin around the neck, arms, breasts, or thighs, usually indicative
  • of insulin resistance

Risk factors for polycystic ovarian syndrome

Risk factors are hormonal and endocrine disorders such as:

  • Cushing syndrome
  • Androgen-secreting tumors in the ovaries
  • Thyroid problems

If left untreated, PCOS can put women at increased risk of:

  • Cardiovascular disease
  • Insulin resistance, type 2 diabetes, or gestational diabetes
  • High blood pressure
  • Strokes
  • Dyslipidemia (disorders of cholesterol and triglycerides)
  • Infertility
  • Obesity or weight gain
  • Miscarriage
  • Sleep apnea

Western medical treatment of PCOS

In the treatment of PCOS, Western medicine attempts to control its symptoms, including:

Treatment of hirsutism or acne: In women not wishing to become pregnant, oral contraceptive pills may be effective in reducing hirsutism and acne. Many other drugs are available to reduce these symptoms, including metformin, flutamide, and spironolactone, although they offer only about a 25% improvement for most patients.

Lowering of insulin levels: Keeping insulin levels under control is important due to the increased risk of serious diseases such as diabetes, cardiovascular disease, stroke and complications during pregnancy if left untreated. Exercise and a low glycemic index diet have been shown to reduce insulin levels and improve menstrual cycle regularity and ovulation. Insulin-lowering medications may be combined with diet and exercise therapy for improved results; the most common of these are metformin (Glucophage), pioglitazone (Actos) and rosiglitazone (Avandia).

Restoration of regular menstruation, and prevention of endometrial hyperplasia and endometrial cancer: If pregnancy is not desired, then menstruation can usually be regulated with a contraceptive pill. For women choosing not to take oral contraceptives, some form of progestogen replacement is recommended if menstruation is occurring less often than every three months. This necessity for a few menstrual cycles per year is to ensure that the endometrium is being shed sufficiently to prevent an increased risk of endometrial abnormalities or cancer.

Secondary treatment for infertility: Treatment of infertility for women with PCOS varies widely and is based on the presentation of the patient. For overweight and anovulatory women, dietary adjustments and weight loss may lead to spontaneous resumption of ovulation. Clomiphene citrate (Clomid) or injectable preparations of FSH are often used to stimulate ovulation, and may or may not be combined with insulin-sensitizing medications such as Metformin. Laparoscopic ovarian drilling is infrequently used currently, but is another option for promoting ovulation. If these methods are attempted and do not result in pregnancy, assisted reproductive technology such as IUI or IVF may be used, although patients with PCOS must be carefully monitored, due to the increased risk of ovarian hyperstimulation syndrome (OHSS)