Polycystic Ovarian Syndrome
Polycystic ovarian syndrome (PCOS) is the most common endocrine problem in women. Around one in every six women probably has the tendency to polycystic ovaries. The condition has a strong genetic tendency. PCOS is a jumble of conditions and symptoms making it a difficult condition to pinpoint the cause of. How it manifests itself is very complex - it has no one cause or trigger.
The understanding of this syndrome by the medical fraternity is still in its infancy and until recently it was thought to be a specifically gynecological problem. However, doctors now recognize that the disorder is associated with insulin resistance in 30 - 60% of cases. There is variation in different racial groups. African Americans, indigenous groups, Islanders and people of Indian sub continental or Chinese origin are at a higher risk.
The term polycystic ovarian syndrome is derived from the presence of small fluid filled sacs or cysts which accumulate in the ovaries from trapped eggs, which were never released from the ovaries. In a normal ovary, a single egg develops and is released each month. In PCOS, normal ovulation or release of the eggs at the middle of the menstrual cycle is inhibited. A woman may have PCOS without actually having the ovarian cysts. It is partly due to a hormonal imbalance.
These three hormones are produced in the ovaries: estrogen, androgens and progesterone.
Because ovulation does not occur very often, these women do not produce adequate amounts of the hormone progesterone but do produce estrogen. This results in infertility and very infrequent menstrual bleeding. This lack of progesterone can also result in heavy irregular menstrual bleeding.
As a result, the follicle, the fluid filled sac that develops around the egg before it ovulates, never develops. Instead, it turns into a cyst on the ovary.
It is the abnormal progesterone level that prevents the follicle from developing. Two more hormones -follicle stimulating hormone (FSH), and luteinizing hormone (LH) - are produced in the pituitary gland in the brain. The hormones produced in the brain regulate the production of the hormones produced in the ovaries. For whatever reason, production of FSH and LH is irregular, so problems develop with the other three hormones as well.
Women with PCOS usually have higher levels of male hormones or androgens, which are produced in their ovaries, adrenal glands and also in their upper level body fat. Therefore, it is desirable for women with this condition to avoid carrying too much body fat. Weight excess will aggravate the hormonal imbalances of PCOS, and is often associated with Syndrome X (see "I can't lose weight! ...and I don't know why"). Women with PCOS have a much higher risk of Syndrome X and a sevenfold increased risk of becoming a type 2 diabetic, especially if they are overweight. The excess of male hormones will increase insulin resistance so that blood glucose problems, high cholesterol, and hypertension may result, especially in overweight women.
Is it common?
Polycystic ovarian syndrome is quite common, researchers suggest approximately 5-10% of women in the United States have PCOS and 6-10% of menstruating women in Australia.
What causes it?
The exact cause of the hormone imbalance that leads to PCOS is unclear. It runs in families, so the tendency to develop the syndrome may be inherited. The underlying cause is thought to possibly be a genetic defect. It is suspected that insulin resistance is due to a defect in the processes which occur after insulin binds to a resistant cell.
What are the symptoms?
The numbers and types of PCOS symptoms that appear vary between women. These include:
- Hirsutism - Excess facial and body hair related to excess androgen production (hyperandrogenism) - this occurs in 70% of women.
- Obesity - Approximately 40-70% of PCOS patients are overweight. Obesity is centered around the midsection.
- Irregular or absent periods - Anovulation appears as a lack of periods (amenorrhea) in 50% of patients, and as heavy uterine bleeding in 30% of patients; however, 20% of PCOS patients menstruate normally.
- Male-pattern hair loss - particularly the temples and crown area. This is known as androgenic alopecia.
- Infertility - Achieving pregnancy is difficult in many women with PCOS.
- Polycystic ovaries - Most, but not all, women with PCOS have multiple cysts on their ovaries.
- Skin discoloration - Some women with PCOS have dark patches on the skin around the neck, groin and under the arms.
- Abnormal blood chemistry - Women with PCOS have high levels of low-density lipoprotein (LDL or "bad") cholesterol and triglycerides, and low levels of high-density lipoprotein (HDL or "good") cholesterol.
- Hyperinsulinemia - Some women with PCOS have high blood insulin levels, particularly if overweight.
- Acne and other skin problems - Acne is seen in about 1/3 of PCOS patients. This is caused by the increased secretion of sebum stimulated by the excess male hormones. Skin tags, thick lumps of skin that can be as large as raisins, can form and usually are found in the armpits or neck. These can easily be removed. Darkening and thickening of the skin also can occur around the neck, groin, underarms, or skin folds. This condition, called acanthosis nigricans is a sign of an insulin abnormality.
- High blood pressure.
- Insulin resistance or diabetes.
Someone with PCOS may have any or all of these symptoms.
The following shows the prevalence of PCOS symptoms in a study (*) on a group of 1741 UK women:
- Polycystic ovaries on ultrasound 100%
- Menstrual cycle disturbance 66%
- Absence of periods 19%
- Obesity 38%
- Infertility 20%
- Excess male hormones (hirsutism, acne, androgenic hair loss) 70%
* Balen & Colleagues, UK.
These symptoms may be found singularly or in combination.
The android body types are more susceptible to conditions such as PCOS due to excess male hormone. Androids commonly suffer from the metabolic imbalance known as Syndrome X. This term refers to a constellation of symptoms/conditions that are associated with excess abdominal fat, raised insulin, raised fasting blood glucose, elevated BP, blood fat abnormalities, raised testosterone levels and the symptoms that accompany this including excess facial and body hair, adult acne, and the development of PCOS. See my book "The Body Shaping Diet" for more information on body types.
Insulin resistance and PCOS
Insulin resistance is common in PCOS patients, and can occur in both obese and lean patients - it is, however, exacerbated in obese patients.
Insulin resistance is often hereditary and usually aggravated by a high carbohydrate diet. Insulin resistance and hyperinsulinemia (high levels of insulin) stimulate the ovaries to produce androgens, and the androgens may exacerbate the collection of symptoms known as PCOS. This interaction of excessive insulin production and excess male hormone is believed to play a role in the lack of ovulation in susceptible women.
The root of insulin resistance is believed to be in the protein-related events occurring within the cell. Some types of cells - most commonly muscle and fat - in the body can be insulin resistant, while other types of cells and organs are not. As a result, the pituitary, ovaries, and adrenal glands of an insulin resistant patient will be stimulated by far higher levels of insulin than would be desired, with the consequences of elevated luteinizing hormone and androgens (male hormone). In previous studies of women with PCOS, most were found to have elevated levels of insulin and a glucose metabolism that was resistant to the effects of insulin.
The primary role of insulin is to regulate blood sugar levels. After you eat carbohydrates, they will be broken down into their component sugar molecules and transported into the bloodstream. Your pancreas then secretes insulin, which shunts the blood sugar into muscles and the liver as fuel for the next few hours.
However, the more abdominal body fat you have, the more insulin your pancreas will pump out per meal, and the more likely you'll develop what's called ''insulin resistance". In effect, your cells become insensitive to the action of insulin, and you need even greater amounts to keep your blood sugar in check. So as you gain weight, insulin makes it easier to store fat and harder to lose it. To date, the belief is that insulin resistance occurs mainly in muscle, but is also present in the liver in obese women with PCOS.
Insulin resistance leads to hyperinsulinemia (elevated insulin levels) because the pancreas will pump out more and more insulin to try and force the blood sugar into the resistant cells. Elevated insulin has been shown to stimulate ovarian androgen production, as the ovaries retain their sensitivity to the insulin even though the muscles and liver have not.
Excess insulin may also stimulate fat storage and alter cholesterol metabolism, leading to elevated cholesterol and triglyceride levels. Because PCOS is such a complex jumble of symptoms and conditions, not all women with PCOS will have insulin resistance; however, for obese sufferers who hold their weight in the abdominal area it is more or less a given. PCOS is very commonly suffered by women with the metabolic disorder called Syndrome X - see my book "I can't lose weight! ...and I don't know why" which has many overlapping symptoms with PCOS.
Is it curable?
With proper diagnosis and treatment, most PCOS symptoms can be adequately controlled or eliminated. Infertility can be corrected and pregnancy achieved in most patients although, in some, the hormonal disturbances and ceasing of ovulation may recur - especially if they return to old lifestyle and dietary habits.
Different diagnostic criteria for PCOS is used in different countries. The UK defines PCOS as the appearance of the follicle cysts on an ultrasound of the ovaries in combination with one or more of the symptoms listed above. In the US the definition is tighter. It requires the combination of irregular periods and excess androgen production but does not take into consideration the ultrasound picture.
It is thought that there are varying levels, cases ranging from most severe where the woman suffers from all the listed symptoms, to a 'normal' woman with only the characteristic cysts on the ultrasound and no other symptoms. It is likely that genetic factors play a part in where a women will be placed along this 'spectrum' of symptom combinations.
It is also likely that a 'trigger' will push her from 'normal' to a more severe expression of symptoms. The most likely triggers are obesity and increased food intake, particularly highly processed starchy carbohydrate foods, lack of exercise and excess male hormone, perhaps from the prescription of oral contraceptive pills or hormone replacement containing 'masculine' type progesterones. The lack of ovulation may lead to irregular heavy menstrual bleeding or lack of periods altogether and hirsutism.
PCOS can be diagnosed by blood tests and a transvaginal sonogram. The blood tests are essential. The doctor should take a complete medical history, including questions about menstruation and reproduction, and weight gain. Physical examination includes a pelvic examination to determine the size of the ovaries, and visual inspection of the skin for hirsutism, acne, or other changes. An ultrasound examination of the ovaries may be performed to evaluate their size and shape.
This disease is often called a mystery disease and is often misdiagnosed because of its varied collection of symptoms.
Many PCOS patients will have abnormal levels of one or more of these tests, although normal values do not rule out a PCOS diagnosis. PCOS can be difficult to diagnose since its symptoms are similar to those of other diseases, and since all of its symptoms may not occur.
Patients should be monitored for endometrial cancer. An endometrial biopsy is essential to rule this out if the woman has missed several periods.
Because of the high rate of hyperinsulinemia seen in PCOS, women with the disorder should have their glucose levels checked regularly to watch for the development of diabetes.
Blood pressure and cholesterol screening are also needed because these women also tend to have high levels of LDL cholesterol and triglycerides, which put them at risk for developing heart disease.
Blood tests should include serum levels of:
- Total testosterone
- Free androgen index
- SHBG (Sex hormone binding globulin)
- LH (Luteinising hormone)
- FSH (Follicle stimulating hormone)
- A glucose tolerance test with accompanying insulin levels
Although insulin sensitizing medications such as Metformin can help those with PCOS, dietary changes remain the best strategy for long term success. The mechanisms by which various treatments affect insulin resistance cover a wide spectrum. The insulin sensitizer Metformin acts by causing the liver to decrease its production of glucose, so that elevated insulin levels do not continue to trigger unneeded glucose secretion.
Some women with PCOS are treated with the oral contraceptive pill, which produces a regular menstrual bleed. However, long term use of the contraceptive pill, especially pills containing masculine synthetic progesterones, may aggravate insulin resistance and weight gain in some women with PCOS.
PCOS can often be controlled very well with weight loss, and the use of natural progesterone and nutritional supplements. Natural progesterone is given in the form of lozenges or creams. Natural progesterone does not aggravate insulin resistance or increase weight, and may help to relieve many symptoms of PCOS. Women with PCOS are generally deficient in the hormone progesterone and will benefit from its supplementation. Use 'Dr Cabot's Fem Pro - Natural Progesterone Cream daily. This delivers a 35 mg dose of real progesterone.
Dietary changes and supplements are vital. It is recommended to follow the "Syndrome X" program. Patients will be able to control their weight by following the basic eating principles of this book.
- Basically, you need to reduce processed starchy carbohydrates and have first class protein with every meal and snack.
- Women with PCOS should eat only organic poultry and meats free of growth promoting hormones.
- PCOS can often be controlled very well with weight loss, and the use of natural progesterone and nutritional supplements. Natural progesterone does not aggravate insulin resistance or increase weight, and may help to relieve many symptoms of PCOS.
- If you want to improve liver function you must avoid ALL dairy products - dairy foods contain high levels of antibiotics, steroids and artificial growth hormones, as this is what the herds are treated with in today's high tech dairies to prevent disease and boost milk production. As with humans where substances go through into breast milk, it is the same for cattle.
- When reducing sugar intake, avoid artificial sweeteners see www.dorway.com
Healthy sweetener guide
Sweeteners to avoid:
- Sucralose (Splenda)
- Acesulfame-K (Sunette, Sweet & Safe, Sweet One)
Sweeteners to use:
Orthodox medical treatment
- Doctors are now prescribing insulin sensitizers such as Glucophage (Metformin), and these drugs help the body use its insulin better and stop overproducing insulin. Although insulin-sensitizing medications such as Metformin can help those with PCOS, dietary changes remain the best strategy for long term success.
- Other treatments currently in development will attempt to directly affect the protein related events within the actual insulin resistant muscle or fat cell.
- Some women with PCOS are treated with the oral contraceptive pill, which produces a regular menstrual bleed, as irregular periods and a buildup of the uterine lining can encourage uterine cancer. An endometrial biopsy is essential to rule this out if the woman has missed several periods. However, long term use of the contraceptive pill, especially pills containing masculine synthetic progesterones, may aggravate insulin resistance and weight gain in some women with PCOS. You should check this with your doctor, as a pill containing synthetic progesterone will trigger male pattern baldness in these women due to higher levels of male hormone. Patients who do not want to become pregnant and require contraception (spontaneous ovulation occurs occasionally in PCOS patients) may be treated with low-dose oral contraceptive pills (OCPs). OCPs bring on regular menstrual periods and correct heavy uterine bleeding, as well as hirsutism, although improvement may not be seen for up to a year.
- 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 OBGYN, GP or regular endocrinologist.
- The anti-androgen drug spironolactone (Aldactone), which is usually given with an oral contraceptive, improves hirsutism and male-pattern baldness by reducing androgen production, but has no effect on fertility. The drug causes abnormal uterine bleeding and is linked with birth defects if taken during pregnancy.
- Another anti-androgen used to treat hirsutism, flutamide (Eulexin), can cause liver abnormalities, fatigue, mood swings, and loss of sexual desire.
- A drug used to reduce insulin levels, metformin (Glucophage), has shown promising results in PCOS patients with hirsutism, but its effects on infertility and other PCOS symptoms are unknown. Drug treatment of hirsutism is long-term, and improvement may not be seen for up to a year or longer.
- Acne is treated with antibiotics, anti-androgens, and other drugs such as retinoic acids (vitamin A compounds).
- If an infertile patient desires pregnancy, the first drug usually given to help induce ovulation is clomiphene citrate (Clomid), which results in pregnancy in about 70% of patients but can cause multiple births. In the 20-25% of women who do not respond to Clomid, other drugs that stimulate follicle development and induce ovulation, such as human menstrual gonadotropin (Pergonal) and human chorionic gonadotropin (HCG), are given; however, 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.
Recommended supplements for PCOS
Take 2 capsules twice daily with meals. Berberine is a plant extract with similar actions to metformin. It reverses insulin resistance.
Take 2 capsules twice daily - A good combination should include herbs, vitamins and minerals to help balance the hormones naturally.
- Livatone Plus Powder or Capsules
Take 2 capsules twice daily before food or 1 teaspoon twice daily stirred into vegetable juice - This will assist the liver to metabolize the excessive levels of male hormones. Also, the liver is the most important fat burning organ in the body. It stimulates the phase 1 and 2 detoxification pathways to improve liver function, which is a very important factor for fertility.
- Glicemic Balance
Take 2 capsules twice daily - A good formula will include the herb Gymnema sylvestre and bitter melon, together with synergistic vitamins and minerals, plus levocarnitine and lipoic acid. This special combination of herbs and nutrients can improve glucose and insulin metabolism.
- Fem Pro - Natural Progesterone Cream
One dose = 1/2 turn of the self-dispensing lid = 1/4 teaspoon of the cream = 35 mg progesterone.
The above statements have not been evaluated by the FDA and are not intended to diagnose, treat or cure any disease.