It is safe to say that most practitioners have had to treat at least one case of polycystic ovarian syndrome (PCOS), with 10% of women of child-bearing age affected.[1] Like most disease states, PCOS is complex and no two cases are exactly the same, guidelines released in 2013 encouraged a fresh approach by medical practitioners, which naturopathic practitioners have long been addressing.
Key symptoms of PCOS are: hirsutism (male-pattern hair on women), infrequent menstrual cycles, anovulation and infertility.[1] Of course another primary characteristic of PCOS is polycystic ovaries, where multiple cysts are seen within one or both ovaries where the egg has matured but has not been released at ovulation each month.
Patients will want to learn what causes their PCOS, and the answer is that there is an excess of androgens (male hormones like testosterone) in the body. Normally, all women have a small amount of testosterone, but why would it become too high? The answer to that is unknown, but there is a connection with genetics, lifestyle, weight and insulin resistance. Sufferers may present with some or all of the following: insulin resistance, dyslipidaemia, low-grade inflammation and an increased risk of type 2 diabetes and cardiovascular disease. Of the women affected, 50% are overweight or obese,[1] and it is this consideration that has led researchers to re-investigate this disease.
Diagnostic Criteria
An Endocrine Society task force developed new guidelines for the treatment of polycystic ovary syndrome (PCOS). The 2013 guidelines, published in the Journal of Clinical Endocrinology & Metabolism, are aimed at helping physicians understand this complex condition.[2,3]
Summary of PCOS guidelines [2,3]
- Diagnose adult woman with PCOS if she has at least two of the following symptoms: excess androgen, ovulatory dysfunction or polycystic ovaries.
- For adolescent girls, diagnosis should be based on clinical or biochemical signs of hyperandrogenism, after excluding other possible causes, in the presence of persistent oligomenorrhea.
- During perimenopause and menopause, diagnosis should be based on a documented, long-term history of oligomenorrhea and hyperandrogenism in reproductive years.
- Rule out other androgen-excess disorders.
- Screen patients for endometrial cancer, mood disorders, obstructive sleep apnea, diabetes and cardiovascular disease.
- In physical examination, look for terminal hair growth, acne, alopecia, acanthosis nigricans and skin tags.
- Screen for ovulatory status using menstrual history.
- Assess body mass index, waist circumference, blood pressure and oral glucose tolerance.
- Screen overweight and obese patients with PCOS symptoms for obstructive sleep apnea.
- Screen and treat for depression and anxiety.
- Recommend hormonal contraceptives as the first-line therapy for menstrual abnormalities and hirsutism/acne.
With these guidelines in place, it was hoped that medical practitioners could more clearly define and diagnose sufferers of PCOS. This would ensure that primary symptoms be identified, whilst ruling out other causes like endometrial cancer, sleep disorders, diabetes, cardiovascular disease and mood disorders, also helping to use medication more effectively where needed. For example, metformin is a diabetic medication and it used often for PCOS, yet has no effect on acne or hirsutism.[2]
One paper, which reviewed nine trials (involving 583 women), found that the use of lifestyle modifications improved fasting blood glucose and insulin levels for women with PCOS. This was a similar result to metformin use.[1]
By adopting this latest diagnostic criteria, the medico is able to quickly identify whether that patient’s PCOS is of a genetic or lifestyle cause, and treat it accordingly; an approach already familiar with natural medicine practitioners who are adept at looking beyond the symptoms by using a holistic approach.
Another group of researchers has taken this ‘new approach’ one step further by calling for PCOS to be redefined as two distinct conditions; one that describes those with a genetic predisposition for PCOS, versus one with more of a diet and lifestyle background (described as ‘metabolic consequences’).[4]
Treatment using Complementary Medicine
After confirming a diagnosis of PCOS, the first-line medical approach is often hormonal contraceptives for menstrual abnormalities and hirsutism, clomiphene for infertility and metformin for diabetic symptoms.[3]
As with any health concern, improvements to diet and lifestyle have a profound impact on a patient’s symptoms. Increased fatty tissue is not only linked to a range of health concerns like increased risk for diabetes and cardiovascular disease, but is also associated with sex hormone abnormalities.[1] Considering the high rate of obesity amongst sufferers, a managed weight-loss program coupled with achievable exercise goals will have an enormous positive impact on patient health outcomes.
In addition to diet and lifestyle management procedures, there are several herbs and nutrients which may help to manage PCOS symptoms. It is important to address the areas of most concern to each patient; which may vary from weight loss and blood glucose regulation in some, to primarily hormonal balancing in others. In many cases, patients will require intervention on both sides.
Some important traditional herbs to consider for the maintenance of healthy blood sugar levels are goat’s rue (Galega officinalis), bitter melon (Momordica charantia), gymnema (Gymnema sylvestre), cinnamon (Cassia cinnamonum) and fenugreek (Trigonella foenum-graecum).[5,6]
There are several nutrients which may also help your client maintain healthy glucose levels. Two principal ones are chromium and alpha-lipoic acid. Chromium works by improving the cell’s ability to take up glucose and use it more effectively, whereas alpha-lipoic acid’s primary quality is its antioxidant power and its ability to provide this to all cells throughout the body.[7,8]
With PCOS, most sufferers will need hormonal imbalances addressed. Herbs are a wonderful way to tackle hormonal issues, as often there is no equivalent in orthodox prescribing. Herbs to assist in menstrual irregularities are vitex (Vitex agnes castus) and peony (Paeonia lactiflora).[12,13] When peony is combined with another herb licorice (Glycyrrhiza glabra), the lutenising hormone (LH):follicle-stimulating hormone (FSH) ratio is lowered along with serum testosterone, which may improve ovulation in women with PCOS.[9,10]
Balancing hormones with nutrients would have to include B6 because it helps to relieve PMS symptoms and support healthy mood associated with hormonal imbalance.[6,10,11]
Natural medicine practitioners know that any hormonal and lifestyle condition needs liver support. Here, the use of milk thistle (Silybum marianum), schisandra (Schisandra chinensis), burpleurum (Burpleurum falcatum), vitamin E, selenium, betacarotene (natural) and fish oils would certainly help reduce free-radicals and support the liver to help metabolise excess hormones associated with PCOS.[6,9]
The take-home message here is that PCOS has a varied list of symptoms and hence it can be a complex condition to diagnose, let alone treat. By using clear symptom criteria, and using lifestyle management where possible, better outcomes can be achieved. As with any new client, finding out about a PCOS sufferer’s unique symptom picture will help you to support them on their journey to better health.
References
- Domecq JP, Prutsky G, Mullan RJ, et al. Lifestyle modification programs in polycystic ovary syndrome: systematic review and meta-analysis. J Clin Endocrinol Metab 2013;98(12):4655-4663. [Full Text]
- Legro RS, Arslanian SA, Ehrmann DA, et al. Diagnosis and treatment of polycystic ovary syndrome: an Endocrine Society clinical practice guideline. JCEM 22 October 2013, doi: 10.1210/jc.2013-2350. [Full Text]
- Laidman J. PCOS: Endocrine Society issues new guidelines. Medscape medical news 2013. [Article]
- Dunaif A, Fauser BC. Renaming PCOS – a two-state solution. JCEM 2013;98(11):4325-4328. [Full Text]
- Braun L, Cohen M. Herbs and natural supplements: an evidence-based guide, 3rd ed. Sydney: Churchill Livingstone Elsevier, 2010.
- Mohamedshah FY, Moser-Veillon PB, Yamini S, et al. Distribution of a stable isotope of chromium (53Cr) in serum, urine, and breast milk in lactating women. Am J Clin Nutr 1998;67(6):1250-1255. [Abstract]
- Wang Y, Dong W, Wang F, et al. Protective effect of α-lipoic acid on islet cells co-cultured with 3T3L1 adipocytes. Experimental Therapeut Med 2012;4(3):469-474. [Full Text]
- Bone K. A clinical guide to blending liquid herbs. St Louis: Churchill Livingstone, 2003, pp.142
- Trickey R. Women’s hormones & the menstrual cycle. St Leonards: Allen & Unwin, 2004
- Wyatt KM, Dimmock PW, Jones PW, et al. Efficacy of vitamin B6 in the treatment of premenstrual syndrome: systematic review. BMJ 1999;318(7195):1375-1381. [Full Text]
- Bone, K. A Clinical Guide to Blending Liquid Herbs. St Louis: Churchill Livingstone, 2003 p.316
- Peony Herbal Mongraph, Natural Standard.
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