Understanding PCOS
Polycystic ovary syndrome (PCOS) is one of the most common hormonal disorders in women. It is commonly associated with infertility, as up to 72% of those with PCOS experience infertility compared to 16% of non-PCOS women with these issues (2). PCOS affects between 6-21% of women of childbearing age however less than 50% of women are properly diagnosed (6), so many remain unaware of what is causing their underlying symptoms (2). Although this may sound alarming, there are effective tried and tested treatments to manage symptoms naturally. These treatments can also potentially reverse the imbalances at the root of the issue.
The three main features are cysts in the ovaries, an excess of male hormones and absent or irregular periods. Although it has been a relatively under-diagnosed condition for a long time, more people are becoming aware of this disorder. This is important because PCOS is associated with an increased risk for developing type 2 diabetes, mood disorders, fatty liver, high blood pressure, high cholesterol, high blood sugar, heart disease and metabolic syndrome amongst other issues.
Simply put, the main issues with PCOS is hormone imbalances. The endocrine (hormone) system is very complex, and there is still much to learn about exactly how these hormone imbalances work in different people. PCOS is often characterized by insulin resistance, which is a hormone released to control blood sugar levels and keep them in safe ranges however other hormones are involved too.
How Does PCOS Work?
Insulin resistance affects 50-70% of all people with PCOS (7), and whilst there are multiple reasons that PCOS can develop it is well accepted that insulin resistance plays an important role. Insulin is the hormone the body uses to maintain healthy sugar levels. People with PCOS often are insulin resistant and can have excessive levels of insulin in the body (hyperinsuinaemia). Paying attention to insulin resistance is important because when left untreated it can increase the risk of getting diabetes, metabolic syndrome, high blood pressure and high cholesterol later on. If insulin is resistant, the pancreas has to make more insulin to keep sugar normal and if it can’t keep up with the increased demand then blood sugar will rise and one can become diabetic.
Sometimes women with PCOS have cysts in their ovaries. Usually during menstruation, a sac forms on the surface of an ovary and it goes away when the egg is released. However if the egg is not released or the sac closes around the egg it can fill with fluid. Then it becomes a cyst, hence the name “polycystic” meaning when somebodies ovaries has multiple cysts on them.
Symptoms such as facial and body hair are also commonplace. The ovaries normally make androgens (male sex hormones), however women with PCOS make slightly more androgens than normal causing the symptoms described. This is known as hyperandrogenism.
Interestingly the hyperinsulinemia (high insulin levels) appears to cause the excess of male sex hormones by increasing testosterone and androstenedione. They in turn interfere with balance in the ovaries, causing an increase in anovulation (a menstrual cycle in which ovulation doesn’t occur), amenorrhoea (when periods stop), increased lutenising hormone levels and this can potentially lead to infertility.
Understanding The Root
The exact cause of PCOS is somewhat unclear, and it is best to speak to a herbalist or health practitioner to get more personalised overview of your health. For serious conditions we always advise to speak to a health practitioner as they can cater treatment specifically to your needs. However, there are some causes and risk factors listed below, that are likely to interact together and initiate development of the illness:
- Metabolic syndrome
- Smoking
- Excessive alcohol consumption
- Sedentary lifestyle
- Epilepsy and/ or use of valproic acid to treat epilepsy
- Type 1 and 2 diabetes (it is unclear which comes first, PCOS or diabetes however it is clear they are linked)
- Premature puberty
- Family history of PCOS
- Altered action of luteinizing hormone
- Insulin resistance
- Acanthosis nigricans (a skin disorder)
- A genetic predisposition to hyperandrogenism
For overweight people, losing weight is one major way to naturally treat polycystic ovarian syndrome. Excess weight is unlikely to be a direct cause, however it can increase severity of symptoms. Reducing adipose tissue (fat) reduces insulin resistance, and therefore helps to rebalance hormones. It must also be stated that there are plenty of people who are of a healthy weight or even under weight who still have PCOS, and this highlights the complexity of the illness and why practitioners must work on a case by case basis.
Doctors will often take measurements of different biomarkers in the body, which give some insight into what is going on.
Biochemical features of PCOS can include:
- High levels of androgens (dehydroepiandrosterone sulphate (DHEAS), androstenedione, testosterone)
- High levels of lutenising hormone (LH) and serum LH:FSH (follicle stimulating hormone)
- High levels of prolactin
- High levels of oestrone. Oestradiol can also be increased though this is not always the case.
- Low levels of sex hormone binding globulin (SHBG)
Oftentimes in order to diagnose PCOS, insulin resistance is assessed as is blood glucose levels. This can be done simply by measuring the fasting blood sugar and fasting insulin level in the morning. Glucose Tolerance Tests are also helpful to measure blood sugar and insulin levels. If insulin levels are higher than average this can indicate resistance. Measuring basal body temperature can also indicate whether somebody is ovulating healthily.
Insulin resistance can lead to complications with the cardiovascular system, high cholesterol and diabetes. However, it is the fluctuation in female hormone production and increase in androgens that can lead to uterine abnormalities and possibly uterine cancer.
Signs And Symptoms
- Painful ovulation
- Oligomenorrhea (irregular periods) or amenorrhea (missing periods)
- Irregular appetite
- Constipation
- Disordered gonadotropin output (gonadotrophins are sex hormones)
- Insulin resistance and elevated fasting blood insulin levels
- Increased ovarian androgen production (an excess of certain hormones)
- Low libido
- Fatigue
- Big changes in mood
- Lack of regular ovulatory cycles (ie no ovulation), menstrual irregularity and infertility
- Obesity
- Fertility problems
- Acne (a sign of hyperandrogenism)
- Oily skin (a sign of hyperandrogenism)
- Excessive hair growth(hirsutism) and hair loss (a sign of hyperandrogenism)
- Weight gain or trouble losing weight
- Anovulatory menstruation and relatively excessive androgen and lutenising hormone are a normal part of puberty for young girls. Early weight gain is now marked as an important indicator for the development of fully fledged PCOS from this normal developmental stage.
Herbal Solutions
- Hemp Seed Oil, Cannabis sativa, is packed with essential fatty acids that help to process cholesterol and support the metabolism (9)
- Karela/Bitter melon, Momordica charantia, reduces fasting & postprandial blood glucose without increasing insulin & appears to enhance tissue sensitivity to insulin
- St Mary’s thistle, gymnema, ginseng, pine bark, Korean ginseng, polygonum and berberine-containing herbs are also helpful for insulin resistance (10)
- Fenugreek, Trigonella foenicum-graecum, reduces fasting blood glucose without increasing insulin (11)
- Gurmar, Gymnema sylvestre, stimulates insulin production (12)
- Guggul, Commiphora mukul, supports thyroid function, clears stagnations and fluid accumulation from the pelvic area.
- Vitex agnus castus, regulates progesterone levels (13)
- Black cohosh can be used for hormone regulation. One must be careful where sourcing black cohosh as it is under threat due to overharvesting. If you are not sure if a product is sustainably sourced then it is best to avoid it to protect the species.
- Chaste tree for hormonal regulation, doses depend on androgen and prolactin levels
- Liquorice and rehmannia support adrenal function
- Psyllium Plantago ovatum reduces postprandial glucose and insulin levels whilst also increasing fibre levels which reduces fasting blood glucose without increasing insulin
- Turmeric, Curcuma longa, for regulating the metabolism and clearing congestion within the pelvis through improving circulation
- Shatavari, Asparagus racemosa, to help clear congestion in the female reproductive tract and support healthy ovulation and improve fertility (14)
- Tribulus can help improve fertility if that’s a goal
- Ashwagandha, Withania somnifera, to support and strengthen the nervous system during periods of stress (15)
- Coleus and Liquorice can be used if it is appropriate to address central obesity as the driver of insulin resistance
- Thuja
- White peony (Paeonia lactiflora) and Liquorice roots has been used in Chinese and Japanese medicine and been shown to have good efficacy in clinical trials. They lower testosterone and raised prolactin levels.
- Motherwort is also traditionally used as a uterine tonic, meaning it nourishes and strengthens the uterus.
For complex conditions herbs are usually prescribed by herbalists as part of a multi-herb formula. An example of this is Jia wei xiao yao wan, a polyherbal formulation commonly prescribed by Traditional Chinese Medicine doctors that contains 8 herbs. Translated as “The Free and Easy Wanderer” there are more details on this formulation and the methodology behind it here. There are also other examples of complex formulas such as Shaoyao Ganchao Tang (8).
Holistic Solutions
Ketogenic Diet
Put simply a ketogenic diet is high in healthy fats and low in carbohydrates. This allows the body to go into ketosis where the liver begins producing ketones to metabolize as energy rather than burning glucose and so fat is burned more quickly. There are various possible benefits of this diet for PCOS. Firstly it has been recommended to improve mental health and brain fog, as women with PCOS are at higher risk of depression. Additionally if being overweight is exacerbating symptoms of PCOS then the keto diet can help speed up the process of weight loss. Finally as the body is burning ketones instead of glucose, it can help with issues of insulin resistance. A pilot study showed success using this diet for women suffering with PCOS (3).
Avoid Endocrine Disruptors
Avoid chemicals that disrupt your hormones. These are also known as endocrine disruptors and include:
- Pesticides
- DBP
- DEHP
- BPA
- Phytoestrogens (plants like yarrow, red clover and soya are phytoestrogens as they increase oestrogen levels)
- Bisphenol A
- Phthalates
- Dioxins
- Pesticides
Acupuncture
Acupuncture has been shown to have positive effects, and is a supportive holistic therapy that can help restore the body back to balance. Scientific studies have shown it to be effective for PCOS (4).
Exercise
Exercise is also important to mention when considering treatment strategies. Exercise enhances tissue sensitivity to insulin; 80% of the body’s insulin mediated glucose uptake occurs in muscles, so regular exercise can help to keep the blood sugar balanced.
Rest Well
Good quality sleep and enough of it is crucial for healthy hormone production, stress control, mood and managing weight.
Vitamin D
Studies show that between 67%-85% of women with PCOS are deficient in vitamin D. This can exacerbate symptoms of PCOS such as weight gain, imbalanced hormone levels, insulin sensitivity, low mood and problems with fertility. Therefore, it is important to make sure one has healthy vitamin D levels.
Bibliography
- Bone K, Mills S. Principles And Practice Of Phytotherapy. 2nd ed. Churchill Livingstone Elsevier; 2013.
- Joham A, Teede H. Prevalence of Infertility and Use of Fertility Treatment in Women with Polycystic Ovary Syndrome: Data from a Large Community-Based Cohort Study. Mary Ann Liebert, Inc., publishers. https://www.liebertpub.com/doi/abs/10.1089/jwh.2014.5000. Published 2021. Accessed July 19, 2021.
- Mavropoulos J, Yancy W, Hepburn J, Westman E. The effects of a low-carbohydrate, ketogenic diet on the polycystic ovary syndrome: A pilot study. Nutr Metab. 2005. https://nutritionandmetabolism.biomedcentral.com/articles/10.1186/1743-7075-2-35. Accessed July 19, 2021.
- Jedel E, Labrie F, Odén A et al. Impact of electro-acupuncture and physical exercise on hyperandrogenism and oligo/amenorrhea in women with polycystic ovary syndrome: a randomized controlled trial. American Journal of Physiology-Endocrinology and Metabolism. 2011;300(1):E37-E45. doi:10.1152/ajpendo.00495.2010
- Thomson R, Spedding S, Buckley J. Vitamin D in the aetiology and management of polycystic ovary syndrome.
- Sirmans S, Pate K. Epidemiology, diagnosis, and management of polycystic ovary syndrome. Clin Epidemiol. 2013:1. doi:10.2147/clep.s37559
- Ovalle F. Insulin resistance, polycystic ovary syndrome, and type 2 diabetes mellitus. Fertil Steril. 2002;77(6):1095-1105. doi:10.1016/s0015-0282(02)03111-4
- Shao Y, Chang Z, Cheng Y et al. Shaoyao-Gancao Decoction alleviated hyperandrogenism in a letrozole-induced rat model of polycystic ovary syndrome by inhibition of NF-κB activation. Biosci Rep. 2019;39(1). doi:10.1042/bsr20181877
- Prociuk M, Edel A, Richard M et al. Cholesterol-induced stimulation of platelet aggregation is prevented by a hempseed-enriched diet. Bridging the Gap: Where Progress in Cardiovascular and Neurophysiologic Research Meet. Can J Physiol Pharmacol. 2008;86(4):153-159. doi:10.1139/y08-011
- Kong W, Zhang H, Song D et al. Berberine reduces insulin resistance through protein kinase C–dependent up-regulation of insulin receptor expression. Metabolism. 2009;58(1):109-119. doi:10.1016/j.metabol.2008.08.013
- Sharma R. Effect of fenugreek seeds and leaves on blood glucose and serum insulin responses in human subjects. Nutrition Research. 1986;6(12):1353-1364. doi:10.1016/s0271-5317(86)80020-3
- Baskaran K, Ahamath B, Shanmugasundaram K, Shanmugasundaram E. Antidiabetic effect of a leaf extract from Gymnema sylvestre in non-insulin-dependent diabetes mellitus patients. J Ethnopharmacol. 1990;30(3):295-305. doi:10.1016/0378-8741(90)90108-6
- Abbaspoor Z. Effect of Vitex agnus-castus on Menopausal Early Symptoms in Postmenopausal Women: A Randomized, Double Blind, Placebo –Controlled Study. Br J Med Med Res. 2011;1(3):132-140. doi:10.9734/bjmmr/2011/163
- Pandey A, Gupta A, Tiwari M et al. Impact of stress on female reproductive health disorders: Possible beneficial effects of shatavari (Asparagus racemosus). Biomedicine & Pharmacotherapy. 2018;103:46-49. doi:10.1016/j.biopha.2018.04.003
- Lopresti A, Smith S. Ashwagandha (Withania somnifera) for the treatment and enhancement of mental and physical conditions: A systematic review of human trials. J Herb Med. 2021;28:100434. doi:10.1016/j.hermed.2021.100434