Polycystic Ovaries and 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. 20-25% of women will have multiple ovarian cysts (PCO) diagnosed by ultrasound of the ovaries but only half or fewer (5-10% of women) will actually have PCOS.
What is the difference between Polycystic Ovaries and PCO Syndrome? PCO is a condition only affecting the ovaries while PCOS involves other body systems and organs other than the female reproductive system, such as the blood sugars and insulin. 40% of women in families with PCOS or Type 2 Diabetes have PCOS, indicating a possible inheritable tendency or underlying cause. What is PCOS? PCOS is a group of conditions that affects 5 – 10% of women. Usually it begins in puberty and worsens with time, although fortunately it is a benign disorder. PCOS is complex because it is so much affected by a woman’s emotions, thoughts, diet and personal history. Instead of producing eggs in the ovary and releasing them once a month, called ‘ovulation, women with PCO/S produce eggs that do not mature properly but develop into multiple cysts on the ovaries. The woman’s body produces too many male hormones, known as androgens. Polycystic ovarian syndrome is one of the most common hormonal problems for women and a risk factor for type-2 diabetes, although it is one of the least publicised risk factors. Many women have PCOS for 20 or 30 years before they develop diabetes, and most don’t realise that their daughters and granddaughters are at high risk too. Between 50% and 70% of women with PCOS have high insulin levels, called Insulin Resistance. Signs and Symptoms:
Irregular or absence of menstrual periods: usually 1st warning sign
Acne: particularly around the jawline, chest and back.
Irregular and profuse menstrual bleeding 30%
Deeper voice and masculine body shape 20%
Alopecia (hair loss/thinning on scalp & pubic hair)
Craving sugars and starchy carbohydrates such as white flour products
Hypoglycemia: imbalanced blood sugar levels
Acanthosis nigricans: dark velvety patches on the skin
Increased abdominal fat: the apple/android shape
Diagnosis: at least 2 of the following:
Chronic or erratic anovulation (no ovulation): follicles on the ovaries fail to release the eggs within resulting in absent or irregular periods. Hormone blood tests: Lutenizing Hormone (LH) is elevated, while Follicle Stimulating Hormone (FSH) is usually low at a ratio of 2:1. Oestrogen levels can be high from conversion in the periphery of the body, such as fat stores, as well as the unopposed oestrogen production by the ovaries. Progesterone and SHBG levels are low, while androgens such as Testosterone, Free Testosterone and FAI are abnormally high. Internal ultrasound examination of the ovaries illustrating 10 or more cysts on the ovary. Ovaries are usually 10ml or more in size. Glucose Tolerance Test (GTT) with Insulin is elevated and SHBG<35 indicate insulin resistance. According to Dr Warren Kidson, the leading endocrinologist on PCOS at the Prince of Wales and Sydney Children’s Hospitals, all women diagnosed with PCO should be screened for insulin resistance and consequent diagnosis of PCOS by a 1 + 2 hour oral GTT: Glucose Tolerance Test with Insulin. Measuring only fasting blood sugar and fasting insulin are not sufficient. This will determine whether it is systemic and whether the woman has already developed Type 2 Diabetes. What causes PCOS? 1.Hormones 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.
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 normalised. In a few women, the fertility clock may not fully mature with periods starting later than usual, between 16-18 years of age, and the menstrual cycles are irregular from the first period onwards. 2. 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 so they require bigger amounts of insulin to remove the same amount of sugar from the blood. Excessive dietary sugars and high glycaemic carbohydrates, Candida infections, mineral deficiencies, stress or excess body fat, particularly abdominal weight, all contribute to excessive insulin secretion by the pancreas.
Smoking, alcohol and caffeine exacerbate insulin resistance and PCOS.
Previous eating disorders, eg.bulimia and anorexia can programme the body into insulin resistance even years afterwards because of the extreme prior blood sugar imbalances. 3. Obesity PCOS women have a lifelong tendency to increased abdominal weight: the android or apple shape, particularly after 30 years of age or pregnancy. Many women with PCOS will gain weight easily and find that losing weight is difficult, despite diet and exercise.
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.
Enlarged fat cells also secrete TNF-alpha and a newly discovered hormone, Resistin that make the muscles more resistant to insulin. However, there is light at the end of the tunnel! A 5% reduction in body weight has been shown to normalize hormones. This is only approximately 5kg for most women which is realistic & achievable
4.Stress 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). These stressors may be current life stressors, emotional and psychological stress or repressed pain from the past. PCOS is not just confined to women who are overweight as previously thought. 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 and acanthosis nigricans (dark velvety patches on the skin)) due to high androgen levels
Infertility: decreased fertilization due to lack of ovulation
Miscarriage due to high LH levels adversely affecting egg quality and late ovulation
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 test for this: cervix only)
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
Osteoporosis: particularly underweight women or women under chronic stress.
The best indicator for the risk of these long-term complications is CRP (a chronic inflammatory marker), a blood test performed by a GP. It is preferable that the CRP count is < 3, although the ideal is < 1. Orthodox Medical Treatment:
In the past, doctors simply prescribed the oral contraceptive pill (OCP), as a standard treatment for PCOS but the dangers of this is now being realised. The Pill simply masks the underlying condition and actually aggravates insulin resistance, hastening the onset of diabetes. A 1997 study of 98 590 nurses in the USA over a long period of time revealed that type 2 diabetes was 60% more prevalent in women taking oral contraceptives! According to Dr Kidson, if a woman is insulin resistant with PCOS, the Pill could be expected to increase the risk of diabetes by at least 100% and possible by 200%. OCPs with cyproterone acetate (Diane-35 ED, Brenda-35 ED) adversely affect blood cholesterol levels, increase cardiovascular risk and increased risk of blood clots. OCP’s “may completely turn off the fertility clock in women with clock problems, so that ovulation and menstruation do not occur when the pill is stopped” (Kidson). Androgen receptor blockers: Androcur & Aldactone effectively block male hormone effects in the body but cause weight gain in high doses; possibly increase insulin resistance; can cause depression in some women; cause a build up of potassium in the blood which must be checked by blood test 3 – 4 weeks after starting treatment or after increasing the dose; cannot be taken during pregnancy.
• If pregnancy is desired, Clomiphene citrate (Clomid/Serophene) or Human Menopausal Gonadotropin
(Metrodin, Humegon, Perganol, Fertinex) is 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; thins the lining of the uterus which decreases implantation rates for fertility. Professor Robert Norman and Dr Ann Clarke in Adelaide were world pioneers when they showed that diet, regular exercise and weight reduction in women with PCOS who had failed to conceive with IVF, caused conception in 75% without IVF!
Surgery: Ablation of ovarian cysts by laser or electrocautery: destroys the follicles on the surface of ovary which successfully reduces androgens for approximately 6 months but can cause pelvic adhesions. Wedge resectioning is done in rare cases nowadays. Oral hypoglycaemic drugs, eg. Metformin and Diabex effectively reduce insulin resistance, although they rarely cause weight reduction by themselves without a diet and exercise programme. However, they are often poorly tolerated commonly causing nausea, diarrhoea and occasionally vomiting. With long term use, this causes a low B12 uptake. They cannot be taken in pregnancy. Slow Release Metformin has been reported as less effective than normal Metformin, although there are less digestive side effects. Naturopathic Treatments for PCOS: Dietary and lifestyle changes are necessary for successful treatment of PCOS and for maintenance of the condition to prevent long term complications. Extensive information and resources are given to help you make healthier choices and control your weight.
Normalising insulin and blood sugar levels is an essential part of treatment by using weight management, exercise, stress reduction techniques, dietary advice, nutritional supplements and herbal medicines.
Hormonal regulation is achieved using specific herbal medicines individually prescribed which work directly on the ovaries, the pituitary gland, the adrenals and any other endocrine system involved, eg. thyroid as PCOS really is a poly-glandular condition. Remedies to re-initiate regular hormonal cycles and ovulation are paramount.
Naturopathic treatment is possible concomitant with IVF treatment. Claudette adjusts the naturopathic remedies so as not to interfere with IVF drugs but in fact, have been shown to increase the chances of successful IVF conceptions.
You will be referred to your doctor or GP for extensive blood testing, unless this has already been done, so as to give a full diagnosis.
Claudette provides comprehensive lifestyle advice including exercise, creative outlets, personal hygiene products, environmental factors, facial and body hair remedies and referrals to complementary and supportive therapies.
Using the work of Christiane Northrup, author of Women’s Bodies Women’s Wisdom, and the work of Vianna Stibal, ThetaHealing®, the emotional connections to PCOS are discussed to address any underlying emotional issues or creativity blocks so as to create healthy boundaries in all areas of your life. Claudette’s supportive approach makes this journey towards optimum health and balance rewarding and empowering.
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
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