Polycystic Ovarian Syndrome (PCOS) is the most common hormonal problem in women in the reproductive age group; one in every six women probably has the genetic tendency to develop PCOS.

In a normal ovary, a single egg develops and is released from the ovary each month. The release of the egg from the ovary is called ovulation.  In Polycystic Ovarian Syndrome (PCOS), normal ovulation is inhibited, and the eggs become trapped in the ovaries. This results in small fluid filled sacs (cysts) in the ovaries. It is however possible for a woman to have PCOS without ovarian cysts and in this case we diagnose it from the symptoms and the blood test results.

If ovulation does not occur there will be a deficiency of progesterone production in the ovary.

The lack of progesterone can result in the following problems: 

  • Premenstrual syndrome with moodiness, anxiety, and depression
  • Heavy menstrual bleeding
  • Irregular or infrequent menstrual periods
  • Low fertility
  • Hair loss

Possible symptoms of PCOS

  • Weight excess Up to 70% of patients with PCOS are overweight. Excess weight tends to accumulate in the abdominal area. However, some women with PCOS are not overweight, and indeed may be underweight.
  • Excess levels of male hormones (androgens) This can result in male-pattern hair loss and the hair line can recede at the forehead and temples and the hair thins at the crown of the head.
  • Acne and other skin problems Acne is more common in PCOS patients. Skin tags may form in the armpits or on the neck. Skin discoloration with dark patches around the groin, neck, and under the arms. This condition is called acanthosis nigricans and is a sign of insulin resistance (Syndrome X).
  • Hirsutism Excess hair growth may be noted on the face and around the nipples.
  • Ovarian cysts Most women with PCOS have multiple small cysts on their ovaries. An ultrasound scan of the ovaries will show an enlarged ovary with a circlet of small follicles around the outside of the ovaries. Severe cases may have larger multiple cysts.

The chemical imbalance of Syndrome X

PCOS is often associated with the metabolic imbalance called "Syndrome X." Syndrome X occurs when the body becomes resistant to the effects of the hormone insulin. This means that the insulin stops working efficiently, and the body compensates by making more and more insulin, and this results in excess levels of insulin. Insulin is a fat storing hormone so that weight gain usually starts to occur even if the patient is not overeating. Insulin resistance is common in PCOS patients occurring in around 60% of diagnosed cases. If the insulin resistance gets worse, the control of blood sugar levels becomes impaired, and this may lead to raised fasting blood glucose (sugar), elevated blood pressure and eventually type-2 diabetes.

Syndrome X can occur in both obese and lean patients - however it is much worse in women who are overweight. It is often hereditary and is usually aggravated by a high carbohydrate diet. In effect the cells become insensitive to the action of insulin, and so ever greater amounts of insulin are required to keep the blood sugar levels under control. As weight is gained, insulin makes it easier to store fat and harder to lose it.

Certain trigger factors can push a woman with very mild PCOS to a more severe expression of symptoms.

The most likely triggers are:

  1. Weight excess and weight gain
  2. Excess calorie intake, particularly from highly processed starchy carbohydrate foods
  3. Lack of exercise

 

Diagnosis of PCOS

It is recommended that all women diagnosed with PCOS should have a Glucose Tolerance Test (GGT) with insulin, in addition to a fasting blood glucose test. This is because many will meet the diagnostic criteria for pre-diabetes or diabetes based on the GTT, although their fasting glucose test registers normal levels. This is the more frightening aspect of this syndrome - the fact that a serious and undiagnosed condition such as diabetes or pre-diabetes, can be slowly brewing over many years, when something could easily be done about it

Blood tests should include levels of -

  • Total testosterone and free testoserone
  • Free Androgen Index (FAI)
  • Estrogen
  • SHBG (Sex Hormone Binding Globulin)
  • LH (Luteninising Hormone)
  • A glucose tolerance test with accompanying insulin levels
  • Cholesterol and triglyceride
  • Fasting Insulin

Treatment Goals

Is PCOS curable?

With proper diagnosis and treatment, most PCOS symptoms can be adequately controlled or eliminated.

Infertility can be corrected and a healthy pregnancy achieved in most patients, although in some, the hormonal disturbances may recur, especially if the patient returns to unhealthy lifestyle and dietary habits and becomes overweight.

The aims of treatment are to -

  1. Reduce the levels of fat both from underneath the surface of the skin and around the organs inside the body
  2. Reduce elevated insulin levels
  3. Improve insulin sensitivity
  4. Decrease elevated androgens
  5. Reduce the effects of unopposed estrogen (estrogen dominance)

Diet

Although insulin-sensitizing drugs such as Metformin can help those with PCOS, it is generally agreed that dietary changes remain the best strategy for long term success. The achievement of a normal healthy body weight has been continually shown to be the most effective long term approach in relieving the symptoms and signs of PCOS. In many cases, it is not necessary to lose a lot of weight and it may be possible to regain regular ovulation with as little as an 8% reduction in body fat

The best diet to follow is one that is low in processed starchy carbohydrate and refined sugars. It can be most effective to avoid all added sugar and all grains such as wheat, rye, barley, oats, rice, and corn. The diet should contain adequate amounts of first-class proteins from eggs, seafood, fresh meat, cheese, whey protein powder and organic poultry. The diet should be high in vegetables of the raw and cooked variety.

If you are battling with a weight problem, you will find the diet plan in my book titled “I Can’t Lose Weight and I Don’t Know Why” very effective for losing your excess weight. This is a low carbohydrate diet and reduces insulin levels and promotes general well being.

Nutritional Supplements

It is possible to help the body to respond better to the effects of insulin and promote fat burning by using nutritional supplements.

 

The most useful supplements for this purpose include

  • Gymnema Sylvestre (GS)
  • Bitter Melon
  • Chromium picolinate
  • Lipoic Acid
  • Carnitine fumarate
  • Selenium
  • Magnesium
  • Berberine

The supplement known as Glicemic balance combines the most important herbs to reduce insulin resistance.

Exercise

Studies have shown that exercise programs that specifically combine aerobic exercise (such as jogging, walking and swimming) along with a resistance program (such as low impact exercise with weights) will improve insulin sensitivity. It seems that the effects last for around 3 to 6 days after the last exercise session. Therefore, exercise is recommended at least three times per week, to get the maximum long term benefit.

Orthodox Treatment

Metformin

Metformin has been shown in some studies to have a beneficial effect on menstrual regulation and has shown promising results in PCOS patients with hirsutism, but its effects on infertility and other PCOS symptoms are unknown. Whether the addition of insulin sensitizing drugs like Metformin to healthy diet and lifestyle changes, is of significant benefit, is still under debate.

 

Hormone balancing

Natural progesterone

Most women with PCOS are deficient in progesterone. Many of these patients can benefit from the use of natural progesterone in the form of creams, troches or capsules. Natural progesterone does not aggravate insulin resistance or cholesterol problems, whereas synthetic progestogens do. Natural progesterone does not increase weight, and may help to relieve many of the symptoms of PCOS.  The use of natural progesterone will confer a protective effect on the lining of the uterus (endometrium) and thus reduce the risk of uterine cancer. Natural progesterone does not provide contraception and may increase fertility.

The oral contraceptive pill (OCP)

Most women diagnosed with PCOS will be put on the OCP to produce a regular menstrual bleed. The OCP can prevent the overgrowth of the uterine lining (endometrium) associated with progesterone deficiency; however natural progesterone can achieve the same benefit. Unlike natural progesterone, the OCP does provide effective contraception. However, the choice of OCP is very important. Many OCPs on the market contain masculinised synthetic progestogens that actually worsen the excess androgen component of PCOS. Progestogens that are best avoided include norethisterone, norgestrel, and levonorgestrel because they are particularly androgenic. These androgenic progestogens will also worsen the other aspects of PCOS, such as insulin resistance and weight gain in some women.

Drospirenone is a new age progestogen that has anti-androgenic activities - it is combined with synthetic estrogen in the brand of the OCP called Yasmin and is useful in managing the symptoms of PCOS.

Other suitable feminine brands of the OCP for women with PCOS are – Diane, Brenda, Juliet, Femoden, Minulet and Marvelon.

Anti male hormones (anti-androgens)

These drugs act by reducing the body’s production of androgens, interfering with the action of the androgens and/or increasing the production of the binding protein called Sex Hormone Binding Globulin (SHBG). Anti-androgen drugs may be used when androgenic symptoms (such as facial hair, excess body hair, balding and acne) are unresponsive to body fat reduction or oral contraceptive pills. It is vital that pregnancy is avoided when taking anti-androgen medications, as these can have a feminising effect on a male foetus.  It is for this reason that anti-androgens are usually combined with, or are part of the OCP.

Examples of anti-androgens are:

  • Cyproterone acetate This drug acts by inhibiting the binding of androgens to receptors on the cell and is a very effective treatment for acne, male pattern baldness and hirsutism.
  • Spironolactone (Aldactone) This drug may be given alone or with an oral contraceptive pill and improves hirsutism, acne and male-pattern baldness. It has no effect on fertility. Spironolactone is not as effective as cyproterone. Spironolactone may cause abnormal uterine bleeding and is linked with birth defects if taken during pregnancy.
  • GnRH Agonists Some patients have severe hirsutism that does not respond to diet, OCPs or anti-androgens. These women may be given monthly injections for six months of a synthetic version of a hormone produced in the brain called GnRH. This chemically 'turns off' the ovaries and induces a medical menopause. The result is a great reduction in the amount of androgens produced by the ovaries.

GnRH Agonist drugs can only be given for 6 months, as they increase the risk of osteoporosis and would only be considered as a last resort after all other approaches have failed. Thankfully the majority of patients will respond very favourably to diet, exercise, nutritional supplementation and hormone balancing.

Other treatments currently in development will attempt to directly affect the protein-related events within the actual insulin resistant muscle or fat cell.

Fertility and pregnancy

A drug that helps to trigger ovulation is the steroid hormone dexamethasone. This drug acts by reducing the production of androgens by the adrenal glands. This condition is best evaluated by a reproductive endocrinologist, rather than an obstetrician-gynaecologist or regular endocrinologist.

If an infertile patient desires pregnancy, the first drug usually given to help induce ovulation is clomiphene citrate (Clomid). Clomid results in pregnancy in about 70% of patients but does increase the risk of multiple births. In the 25% of women who do not respond to Clomid, other drugs that stimulate follicle development and induce ovulation can be tried. These include human menopausal gonadotropin (Pergonal) and human chorionic gonadotropin (HCG), and these drugs have a lower pregnancy rate (less than 30%), a higher rate of multiple pregnancy (from 5-30%, depending on the dose of the drug), and a higher risk of medical problems.

PCOS patients have a high rate of miscarriage (30%), and may be treated with the gonadotropin-releasing hormone agonist leuprolide (Lupron) or luteal support agents such as progesterone to reduce this risk.

The above statements have not been evaluated by the FDA and are not intended to diagnose, treat or cure any disease.

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