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Polycystic Ovarian Syndrome (PCOS)

Polycystic Ovarian Syndrome (PCOS) is the most common endocrine disorder in women of reproductive age, affecting approximately 5-10% of this population. The diagnostic criteria, known as the Rotterdam criteria suggests a diagnosis if 2 or more of the following are present:

  • Oligo-ovulation or Anovulation – Oligo-ovulation is irregular ovulation, which is typically characterized by menstrual cycles longer than 35 days in length. Anovulation is the lack of ovulation, and therefore absent menstrual cycles.
  • Hyperandrogenism – this can be biological (increased androgens on serum blood testing – testosterone, DHEA-S and androstenedione) or clinical (having symptoms associated with increased androgens such as acne, abnormal hair growth or thinning hair on the scalp)
  • Polycystic Ovaries on Transvaginal Ultrasound – this is typically characterized by 25 or more cysts per ovary or an ovarian volume of 10mL or more.

Because only two of these criteria are required in order to be diagnosed with PCOS, there are several combinations that can occur. For example, you can have Ovulatory PCOS in which you have regular menstrual cycles, but have symptoms of hyperandrogenism and have confirmed polycystic ovaries. Another example includes Non-Polycystic Ovaries in which there is abnormal menstrual cycles and hyperandrogenism, but no confirmed cysts on the ovaries. Therefore, you are able to meet the criteria of Polycystic Ovary Syndrome without having polycystic ovaries.

Symptoms of PCOS

It used to be thought that there was a specific phenotype for PCOS that included obesity, abnormal hair growth, acne male pattern baldness etcetera. However, today there are many presentations of PCOS which may include all or very few of these characteristics. Some of the common symptoms of PCOS include:

  • Irregular menstrual cycle
  • Acne
  • Weight gain
  • Hirsutism – abnormal hair growth in areas of the body which may include the chin, neck, abdomen, chest, back, hands etc.
  • Oily skin
  • Thinning hair on the scalp
  • Acanthosis Nigricans – dark patches of skin in the armpits, on the neck or between the breasts

The “cysts” that are often visualized in PCOS aren’t actually fluid filled cysts, but are rather clusters of immature follicles in the ovary. In a normal cycle, each month there are follicles that develop, grow and mature. The dominant follicle contains the egg that is ovulated and is either fertilized or shed through the menstrual cycle. Since the follicles never fully develop in PCOS, ovulation often does not occur and therefore fertility is reduced.

Insulin Resistance

One of the most common underlying factors that drives PCOS is insulin resistance. This is when our cells are not as sensitive to insulin as they should be and therefore it is not utilized appropriately. This results in blood sugar dysregulation leading to higher than normal blood sugar levels after meals, similar to what is seen in a patient with diabetes. Because of this imbalance, women with PCOS often experience weight gain or difficulty losing weight. There is also an increased risk for cardiovascular disease and the development of type 2 diabetes.  Insulin resistance may also have negative effects on ovulation, which is often already suppressed in patients with PCOS due to hormonal imbalance and elevated androgens.

Another risk factor that should be taken into consideration in patients with PCOS is endometrial cancer due to endometrial hyperplasia. With delayed or absent periods, the uterine lining continues to build but is never shed. After several months there is an increased risk for abnormal cellular growth. It is important to have a period every 3 months to reduce this risk. While working on underlying causes of menstrual cycle dysfunction, a drug-induced cycle using synthetic progesterone may be recommended by your doctor.

Treatment Options for PCOS

The conventional treatment options for PCOS often include metformin, the birth control pill or androgen reducing drugs such as spironolactone. These options often come with side effects and don’t treat the underlying causes of PCOS.

There are many naturopathic treatment options that have shown to be successful in cases of PCOS. These include:

  • Myo-Inositol – this is a supplement that is often found in powdered form, and is added to water daily. It can improve ovulation, insulin resistance and egg quality. Myo-inositol has been found to be comparable to Metformin at improving insulin sensitivity and menstrual cycle length, but with less side effects 1,2.
  • N-Acetyl Cysteine (NAC) – NAC is a precursor to glutathione, which is an important antioxidant in PCOS. Studies have shown that NAC is comparable to Metformin at improving insulin resistance, menstrual regularity, lipid profiles, androgen levels and egg quality 3,4,5. For more information on n-acetylcysteine and PCOS, read this blog post.
  • Vitamin D – many people living in North America are deficient in Vitamin D. Low levels are associated with inflammation and hormone dysfunction. Studies have found that vitamin D is crucial for ovulation, implantation and reducing the risk of miscarriage 6,7,8.
  • Diet – a low glycemic diet is beneficial in PCOS patients because it helps to control blood glucose levels, which is important when there is insulin resistance or insensitivity. Often times this diet includes:
    • No added sugars – refined sugars such as white or brown sugar as well as natural sugars such as maple syrup, honey, agave, coconut sugar should all be minimized. These all affect our blood sugar and insulin in similar ways. Of course, it is best to choose a more natural option when necessary, but reduction is key.
    • No processed foods or refined carbohydrates – avoid anything that comes in a package or has a long list of ingredients. Foods such as store bought breads, pasta, muffins, cookies, baked goods, white rice should all be minimized.  Focus on carbohydrates from vegetables and fruit, sweet potato, quinoa, brown rice etc.
    • Include healthy fats – fats are important for hormone production and blood sugar regulation. Foods such as coconut oil, avocados, nuts (almonds and walnuts have been studied to be beneficial in PCOS), seeds, olive oil and cold water fish such as salmon.
    • Vegetables – this should be at least half of your plate. Aim for lots of green leafy veggies.
    • Fruit – try to focus on low glycemic fruit such as berries rather than sweeter fruit such as grapes or pineapple. Choose whole fruit over fruit juices as fibre in whole fruit helps to stabilize blood sugar.
    • Lean protein – chicken, turkey, fish or legumes will help keep blood sugar levels stable. Aim to have healthy fat and protein at each meal.
    • Reduce dairy – this is especially important if you are prone to acne. Try alternatives such as unsweetened nut, soy or oat milk rather than cows milk.
  • Spearmint tea  – one study found that consuming 2 cups of spearmint tea per day for 30 days reduced androgen levels in PCOS patients. This can support reducing symptoms such has acne, hair growth on the body or hair loss on the scalp9.
  • Exercise – moderate intensity physical activity can improve insulin resistance, assist in weight loss, improve ovulation and elevate mood. It is also beneficial for overall wellbeing and cardiovascular health.
  • Avoid Endocrine Disrupting Chemicals – Although it is extremely hard to avoid endocrine disrupting chemicals, it is important to make an effort to reduce your exposure because these chemicals can worsen endocrine imbalances.
    • Avoid ingredients such as parabens, phthalates, BPA, propylene glycol, triclosan, sodium laurel sulfate, fragrance or parfum.
    • Reduce the amount of plastic you use by bringing your own bag and storing food in glass jars or silicone bags rather than plastic containers.
    • Opt for emailed receipts rather than paper, as paper receipts can contain BPA.
    • Choose more natural, chemical-free cleaning products and cosmetics. Environmental Working Group is a great resource for finding safe products that don’t contain these endocrine disruptors. They also have a database called Skin Deep for cosmetic and personal care products.

PCOS is a very complex condition that can manifest differently in every individual. It is important to seek appropriate care from your Medical Doctor and Naturopathic Doctor in order to receive a treatment protocol that is specific to your case.

References

  1. Pundir J, Psaroudakis D, Savnur P, Bhide P, Sabatini L, Teede H, et al. Inositol treatment of anovulation in women with polycystic ovary syndrome: a meta-analysis of randomised trials. BJOG: An International Journal of Obstetrics & Gynaecology 2017;125:299–308.
  2. Fruzzetti F, Perini D, Russo M, Bucci F, Gadducci A. Comparison of two insulin sensitizers, metformin and myo-inositol, in women with polycystic ovary syndrome (PCOS). Gynecological Endocrinology 2016;33:39–42.
  3. Javanmanesh, F., Kashanian, M., Rahimi, M., & Sheikhansari, N. (2015). A comparison between the effects of metformin andN-acetyl cysteine (NAC) on some metabolic and endocrine characteristics of women with polycystic ovary syndrome. Gynecological Endocrinology, 32(4), 285-289.
  4. Oner, G., & Muderris, I. I. (2011). Clinical, endocrine and metabolic effects of metformin vs N-acetyl-cysteine in women with polycystic ovary syndrome. European Journal of Obstetrics & Gynecology and Reproductive Biology, 159(1), 127-131.
  5. Cheraghi E, Mehranjani MS, Shariatzadeh MA, Esfahani MHN, Ebrahimi Z. N-Acetylcysteine improves oocyte and embryo quality in polycystic ovary syndrome patients undergoing intracytoplasmic sperm injection: an alternative to metformin. Reproduction, Fertility and Development 2016;28:723.
  6. Li N, Wu H, Hang F, Zhang Y, Li M. Women with recurrent spontaneous abortion have decreased 25(OH) vitamin D and VDR at the fetal-maternal interface. Brazilian Journal of Medical and Biological Research 2017;50.
  7. Bärebring L, Bullarbo M, Glantz A, Hulthén L, Ellis J, Jagner Å, et al. Trajectory of vitamin D status during pregnancy in relation to neonatal birth size and fetal survival: a prospective cohort study. BMC Pregnancy and Childbirth 2018;18
  8. Pal L, Zhang H, Williams J, Santoro NF, Diamond MP, Schlaff WD, et al. Vitamin D Status Relates to Reproductive Outcome in Women With Polycystic Ovary Syndrome: Secondary Analysis of a Multicenter Randomized Controlled Trial. The Journal of Clinical Endocrinology & Metabolism 2016;101:3027–35.
  9. Grant, P. (2009). Spearmint herbal tea has significant anti-androgen effects in polycystic ovarian syndrome. a randomized controlled trial. Phytotherapy Research.

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