Polycystic Ovaries
Polycystic Ovarian Syndrome (PCOS)


Polycystic Ovary Syndrome (PCOS) is a condition associated with many cysts or closed pouches containing fluid or solid material consisting of 1 or more chambers in the ovary. 20% of women will have multiple ovarian cysts diagnosed by ultrasound of the ovaries but only half or fewer (5-10% of women) will actually have PCOS. Women with PCO should be reassured they will not usually progress to PCOS. The difference is that PCOS involves other body systems and organs other than the female reproductive system. 40% of women in families with PCOS have PCOS, indicating a possible inheritable tendency or underlying cause. Usually it begins in puberty and worsens with time, although it is a benign disorder.
Signs and Symptoms:
Diagnosis must include at least 2 of the following:
Anovulation (no ovulation): follicles on the ovaries fail to release the eggs within. This results in irregular or absence of menstrual periods, infertility (75% of women with PCOS), hirsutism: excess body hair 60%, obesity 40%, acne, irregular and profuse menstrual bleeding 30%, deeper voice and masculine body shape 20%, alopecia (hair loss/thinning).
Blood tests: Lutenizing Hormone (LH) is elevated, while Follicle Stimulating Hormone (FSH) is usually low at a ratio of 2:1. Oestrogen levels are high from conversion in the periphery of the body, such as fat stores, of androgens (male hormones) into oestrogens (female hormones) as well as the unopposed oestrogen production by the ovaries. Progesterone and SHBG levels are low, while androgens such as Testosterone, FAI and DHEAS are abnormally high.
Ultrasound examination of the ovaries illustrating 10 or more cysts on the ovary. The ovaries are enlarged with smooth thickened capsules or normal in size. Typically the ovary contains many 2-6mm follicular cysts; thecal hyperplasia surrounds the granulosa cells. Large cysts containing ateric cells may be present.
Causes and pathogenesis:
Our hormones are controlled by the pituitary gland in the brain where Lutenizing Hormone (LH) and Follicle Stimulating Hormone (FSH) are produced. Directly above this is the brain's fertility centre or clock that regulates these hormones' production. In a woman, this centre works in a cyclic fashion, once every month, while in a man it works in a continuous fashion. In PCOS, there has been a functional derangement of this centre and thus also of these hypothalamic-pituitary hormones. Excess LH production causes excess androgen production in the follicles inside the ovaries, which prevent ovulation and normal follicular development, resulting in the formation of small cystic follicles instead of mature follicles. These immature follicles do not develop into the corpus luteum as ovulation has not taken place. Therefore, progesterone levels are virtually nonexistent and the ovaries are unable to convert the androgens (male hormones) into oestrogens.
The abnormally high levels of androgens, primarily testosterone and androstenedione, are responsible for the development of acne, male-pattern hair loss, excessive facial and body hair, and acanthosis nigricans (dark velvety patches on the skin). The oestrogens also stimulate the continued release of LH that remains elevated abnormally due to anovulation. High oestrogen levels that are unopposed by progesterone stimulate cell proliferation of the lining of the uterus, the endometrium.
Long Term Complications of PCOS
Implementing prevention strategies now are crucial to any treatment and have also been shown to be very effective at reducing the increased risks of:
Hirsutism (excess body and facial hair, acne, balding, deepening of voice, masculine body shape) due to high androgen levels
Infertility: decreased fertilization due to anovulation
Miscarriage due to high LH levels adversely affecting egg quality
Endometrial hyperplasia and uterine cancer: increased cell proliferation or thickening of the uterus lining is caused by the unopposed oestrogens which is a precursor to endometrial cancer. A woman must have a minimum of 5-6 menstrual periods per year or if she is over 35 years of age, a period almost monthly. (Pap smears do not detect this: cervix only)
Hormonal and menstrual disturbances
Type 2 Diabetes mellitus due to insulin resistance and obesity: diet and lifestyle changes shown to be more effective than drug therapy in prevention trials
Heart disease: increased risks of cardiovascular disease, hypertension, heart attack and atherosclerosis
Orthodox Medical Treatment:
High dose oral contraceptive pill (OCP) or 7-10 days of progesterone therapy (Progestin) each month to suppress ovarian hormone production and reduce the risk of endometrial cancerous changes. Endometrial biopsy or ultrasound is advised if there has been no ovulation for many years or if the woman is more than 35 years old. However, these OCPs with cyproterone acetate (Diane-35 ED, Brenda-35 ED) adversely affect blood cholesterol levels and increase cardiovascular risk. Long term use can exacerbate insulin resistance (discussed below) which may make symptoms worse when you want to come off the OCP at a later date, particularly for women who are already overweight and therefore, increases risk of Type 2 Diabetes.
Androgen receptor blockers: Androcur (cyproterone) & Aldactone (spironolactone) stop the binding of activated testosterone to receptors on skin and hair follicles, decreasing excess hair growth and acne. The effects may take 6-12 months to appear and are lost soon after stopping treatment. Both drugs can make irregular periods worse and cannot be taken if trying to conceive or during pregnancy.
If pregnancy is desired, Clomiphene citrate (Clomid/Serophene) or Gonadotrophin injections(Metrodin, Humegon, Perganol, Fertinex = similar or identical to FSH & LH) are given to induce ovulation. These drugs have side effects and risks, eg. Clomiphene can cause ovarian enlargement and development of several follicles, increasing the risk of ovarian cysts; ovaries become resistant over time; can lead to ovarian hyperstimulation, causing permanent ovarian damage; increases the risk of ovarian cancer by 3 times if taken longer than 1 year, increases the chance of multiple and ectopic pregnancy; increases risk of vascular and pulmonary complications; increases risks of birth defects by 6 times.
Ablation of ovarian cysts by laser or electrocautery: successfully reduces androgens for approximately 6 months but can cause pelvic adhesions. As the cysts are only symptoms of PCOS, not the cause, their removal is only temporary and they keep reoccurring.
Oral hypoglycaemic drugs, eg. Metformin, are very effectively used to reduce insulin resistance. However, they are often poorly tolerated causing digestive and bowel upset. With long term use, this causes a low B12 uptake. They are contraindicated during pregnancy.
Naturopathic Treatment involves:
Weight Control
PCOS women have a lifelong tendency to increased abdominal weight: the android or apple shape, particularly after 30 years of age or pregnancy.
Excess body fat activates aromatase in peripheral tissues and fat cells converting androgens into oestrogens. This has a negative feedback via the hypothalamus to increase LH, creating a vicious cycle of excess androgen production. Androgens are also converted in peripheral tissues into more potent forms by the enzyme 5-a-reductase: eg. Testosterone into Dihydrotestosterone. Enlarged fat cells also secrete TNF-alpha and a newly discovered hormone, resistin that make the muscles more resistant to insulin.
A 5% reduction in body weight has been shown to normalize hormones. This is approximately 5kg only for most women.
However, very low body weight activates the release of adrenaline from the adrenals as the body is not provided with enough energy. This stimulates more insulin release (see below). Also GnRH production is stopped at <16% body weight, causing a cessation of menstruation and decreased conversion of androgens into oestrogens in the periphery, resulting in androgen accumulation.
Weight is normalized through the use of either the ketogenic or zone diets, with nutritional supplements, exercise regimes and herbal medicines.

Insulin Resistance
Insulin is a hormone secreted from the pancreas to control blood sugar levels by allowing the body's cells to take up and use sugar (glucose) for energy. Many women with PCOS have elevated levels of insulin in their blood, causing insulin resistance where the cells no longer respond to insulin.
Excessive dietary sugars, candida infections, mineral deficiencies, stress or excess body fat, particularly abdominal weight, all contribute to excessive insulin secretion by the pancreas in order to try and normalize blood sugar levels by getting the sugar into the body's cells and out of the bloodstream.
Insulin inhibits Sex Hormone Binding Globulin (SHBG) that normally removes circulating androgens and oestrogens to be detoxified and broken down by the liver. The result is elevated androgens and oestogens left in the blood stream.
Insulin also increases androgen production in the ovaries and the adrenals by stimulating the enzyme cytochrome P450c 17-alpha.
Insulin increases LH production by the pituitary gland.
Normalizing insulin and blood sugar levels is an essential part of treatment and are controlled using weight management, exercise, stress reduction, dietary advice, nutritional supplements and herbal medicines.

Stress Management
Stress stimulates adrenaline secretion by the adrenal glands that in turn stimulate insulin secretion to provide an immediate energy source for the body cells for "fight/flight".
Under chronic stress excess cortisol is released from the adrenals producing excessive prolactin secretion, which in turn further decreases FSH and increases LH (via decreasing GnRH). Also stress causes elevated androgen production from the adrenals themselves.
Various stress management techniques are employed along with herbal medicines to calm and support the overactive nervous system and adrenal glands.
Excessive Facial/Body Hair and Acne:
Herbal medicines and specific nutrients have been shown in clinical trials to reduce androgen production and decrease these symptoms.
For increased facial/body hair growth, treatment either naturopathically or with medical drugs will take 6-12 months.



Liver and bowel treatment:
The liver detoxifies and breaks down the hormones, removing them from the blood circulation via the enzyme cytochrome p450 hydroxylation. The liver regulates SHBG and the high LDL:HDL cholesterol ratio. Thus, liver detoxification is an integral part of treatment using herbal medicines.
Correction of any digestion problems to ensure assimilation of nutrients and relieve constipation where oestrogens are reabsorbed into the bloodstream.
Nutrition:
Several supplements are essential to reduce excess androgens, improve insulin function and hormonal regulation by the ovaries. Individual variations exist, although prescriptions usually include B vitamins, zinc, magnesium, chromium, Omega 3 oils.
Thorough dietary advice is given using the glycaemic index, dietary fibre and the zone diet. Avoidance of dietary synthetic oestrogens is essential, eg. pesticides.
Previous eating disorders, eg. bulimia and anorexia have been shown to upset the pituitary fertility clock and thus, hormonal regulation even years after eating is normalized.
Smoking, alcohol and caffeine exacerbate the condition.


Hormonal regulation using Herbal medicines:
Specific herbal medicines prescribed by a naturopathic practitioner work directly on both the ovaries and the pituitary gland to regulate hormones, drain ovarian cysts, initiate ovulation, correct abnormal bleeding patterns as well as support the adrenal glands and liver.
Naturopathic treatment is possible concomitant with IVF treatment. Naturopathic remedies are adjusted so as not to interfere with IVF drugs but in fact, have been shown to increase the chances of successful IVF conceptions.

Article provided by:

Claudette Wadsworth
BA, BHlthSc, AdvND, DN, DRM, AdvNFM, MATMS
at the
Life Natural Healing Clinic - click here - for mor info
Naturopath, Herbalist, Nutritionist, Natural Fertility Management Practitioner, Sydney CBD & Bondi Junction


References
Anderson, K. (1998) Mosby's Medical, Nursing & Allied Health Dictionary. (5th ed.) USA: Mosby.
Berkow, R. (1992) The Merck Manual of Diagnosis and Therapy. USA: Merck Research Laboratories.
Bone, K. (1997) Clinical Applications of Ayurvedic and Chinese Herbs. Australia: Phytotherapy Press.
Kidson, D. (2001) The Polcystic Ovary Syndrome - Advances over the past decade. Royal Hospital for Women: Sydney, Australia.
Lehniger, A., et al. (1993) Principles of Biochemistry. (2nd ed.) NY: Worth Publishers.
Metagenics. (1999) Understanding the Causes of Hormonal Disturbances in Women. Seminar Series Feb-Mar 1999. Australia: Metagenics.
Murray & Pizzorno. (1996) Encyclopedia of Natural Medicine. UK: Little, Brown & Company.
Murray & Pizzorno. (1996) Textbook of Natural Medicine. UK: Little, Brown & Company.
Polycystic Ovarian Syndrome Association. (1997) Polycystic Ovarian Syndrome Fact Sheet. Australia.
Porth, C. (1998) Pathophysiology: Concepts of Altered Health. USA: Lippincott.
Trickey, R. (1998) Women, Hormones and the Menstrual Cycle. Australia: Allen & Unwin.
Trickey, R. & Villella, S. (2002) Polycystic Ovarian Syndrome - A clinical perspective. Proceedings from the Australasian Herbal & Nutritional Conference. Sydney Australia, March 1-2