Poly Cystic Ovarian Syndrome PCOS

Who gets it?

20% of women show on ultrasound to have polycystic ovaries. 5-10% of these have polycystic ovary syndrome (PCOS)

What is PCOS?

Women with PCOS experience “anovulation” or lack of regular ovulation, causing infrequent or irregular periods, however some women although ovulating infrequently still experience regular periods.

Male hormone production is also a common feature of PCOS causing acne, excess body hair growth or loss of scalp hair.

The word syndrome indicates that a number of symptoms occur together, so there can be a wide number of symptom and physical signs with PCOS. These include insulin resistance and raised serum lipids.

Diagnosis

Commonly by ultra-sound, although some women may have PCOS symptoms and show clear on ultrasound. A better view of the ovaries can be achieved by using the ultrasound head inside the vagina, especially if the woman is over weight. Experienced technicians are also better at identifying PCOS ie those specialising in gynaecology.

What causes PCOS

Every woman has a centre in her brain called the pituitary or fertility clock, which regulates the monthly cycle of hormone production by releasing follicle stimulating hormone (FSH) and lutenising hormone (LH). In men it works in a steady continuous fashion, so over exposure to male hormones can influence a woman’s fertility clock to stop working cyclically.

FSH stimulates the growth of the egg-containing follicle. Just before mid-cycle a large surge of LH causes the final step in maturation of the follicle and results in ovulation, the release of the egg.

In PCOS this pattern is disrupted. If periods begin late this is an indication that the fertility clock has not fully matured and so there is a lack of coordination of pituitary gland secretion of FSH and LH and hence incomplete development of the follicle and egg.

Eating disorders such as anorexia and bulimia cause weight loss, which can turn the clock off, and periods disappear. Even if appearing to recover to normal periods these women are prone to irregular periods in the future with male hormone excess and hair growth indicating the ovaries have become polycystic.

The adrenal glands always make a small amount of male hormone testosterone as a by-product of cortisone, the main hormone produced by the adrenal glands. Congenital adrenal hyperplasia may cause high levels of male hormone production and so disrupt the fertility clock from its cyclic pattern. In these cases there is elevated levels of 17 hydroxyprogesterone in the blood.

Women who have a sex change operation are also prone to develop PCOS due to the effects of supplemented testosterone.

The most common cause of PCOS is insulin resistance. Insulin is made the pancreas and released into the blood after a meal to stimulate the cells to suck up the glucose out of the blood and into the cells to use for energy production, building or storage in fat cells. If a diet high in carbohydrates is consumed regularly without a good balance of protein and fat, cells can become resistant or immune to the effects of insulin. While there is still plenty of glucose in the blood the body continues to release more insulin to bring it down, and eventually the cells respond and blood glucose goes down. The high levels of insulin then remain in the blood for some time and inhibit the release of stored energy to maintain a balance supply of glucose in the blood between meals leading to sugar cravings which sets the cycle off again.

Fat cells may not be resistant to insulin so they work overtime sucking up glucose and fat and storing fat. Obesity is a common result. Enlarging fat cells secrete a variety of hormones including TNF alpha and a newly discovered hormone resistin. These hormones act on muscle cells to make them more resistant to insulin adding to the viscous cycle of high insulin production and fat storage. High levels of insulin stimulate an enzyme called cytochrome P450c 17 alpha in the ovaries and adrenal glands to produce increased amounts of male hormone. High levels on insulin in the blood also stimulate the pituitary to increase baseline levels of LH, but does not stimulate a surge in secretion. This also increases the enzyme making testosterone in the ovaries. Some other factor in PCOS allows the follicle to be stimulated for maturity at 4.5mm instead of 9.5mm, so it tries to mature before it is able and ovulation does not occur.

Women whose PCOS is caused by insulin resistance have high blood insulin levels, a normal time of menstruation onset, the period may be irregular from the beginning or more commonly be regular for a year or two and then become irregular. There is commonly a family history of Type 2 diabetes and diabetes in pregnancy, a history of easy weight gain and difficult fat loss. Oral glucose testing can help identify insulin resistance. The upper limit of normal for insulin in the fasting state is 9.0mU/L. This may be elevated to 80mU/L and peak at 2 hours rather than one hour. Measures of the cholesterol fractions HDL, LDL and VLDL will help assess heart disease risk. Other factors that indicate a woman is insulin resistant is raised LH, low sex hormone binding globulin and a distribution of body fat between the waist and face with an increased ration of the waist circumference to hip circumference

Other causes of increased testosterone include the follicles themselves, which are lined by two types of cells theca and granulosa, when ovulation does not occur these cells should self-destruct. In PCOS the theca cells do not die and prevent the follicle from collapsing and this is how the cyst is formed. The theca cells take cholesterol from the blood stream and turn it into androstenedione, a weak male hormone, this is taken up by the adjacent granulosa cells to make oestrone a weak female hormone that then become oestradiol a strong female hormone. After a failed ovulation in PCOS and the granulosa cells die, the theca cells are left to turn all the cholesterol into androstenedione and then into testosterone.

Side effects of PCOS

A result of PCOS is infertility due to irregular ovulation. It takes the average woman 9 to 10 ovulations to fall pregnant so if in PCOS ovulation only occurs 4 times a year it may take 2 – 3 years for her to conceive.

PCOS suffers have an increased risk of type 2 diabetes or impaired glucose tolerance. By age 44 40% of women with PCOS have developed these conditions, if you are over weight the risk is even greater.

Some women with PCOS also have abnormal blood lipids usually low HDLs which are protective against cholesterol and heart disease.

Cancer of the womb is a greater risk if a woman does not ovulate as the ovaries never get to produce progesterone from the old follicle, which is protective against the proliferative effects of oestrogen which causes the lining of the uterus to grow through the cycle. So the womb may develop endometrial hyperplasia.

How can we treat PCOS

The medical method

Address the symptoms and side effects of hair growth, reduced fertility, obesity, diabetes, heart disease and endometrial hyperplasia.

• Hair growth: diet, exercise weight reduction, demamethasone ( synthetic cortisone reduces the production of cortisone and male hormones in the adrenal gland), metformin (lowers male hormone by 50%) spirolactone, cyproterone and flutamide (reduce the effects on testosterone on skin and hair and pituitary, best taken in combination with other treatment)
   
•  Reduced fertility: clomiphene (an anti-oestrogen that trick fertility centre into thinking there is low oestrogen and cause a surge of LH and FHS to stimulate ovulation) gonad atrophin injections (hormones similar to FSH and LH directly stimulate egg and follicle development and ovulation). Diet exercise and weight reduction will lower male hormone levels and allow regular ovulation. Metaformin is more effective than clomiphene in stimulating ovulation and both together are particularly effective. Improve insulin resistance and lower insulin levels through diet with obesity. Metaformin makes the liver and muscles respond better to insulin, may be helpful where diet and exercise are unsuccessful.
   
• diabetes
   
• heart disease
   
• endometrial hyperplasia

Natural treatments

Treatment aims:

• reduce masculinising effects of androgens
• stimulate ovulation
• protecting endometrium
• improving blood sugar balance
• preventing heart disease

When the condition is severe, PCOS may take some time to regulate and the time of exposure of unopposed oestrogen and endometrial hyperplasia is increased. Natural medicines may be more suitably used with or after drug therapy to maintain normal menstrual patterns, reduce the effects of unopposed oestrogens and reduce the risk factors for cancerous change.

Managing PCOS naturally revolves around diet (low fat, whole food, mostly vegetarian) and herbal hormonal regulation. Weight loss alone can help in obesity.

For an individualised program of diet, nutrition, herbs, flower essences and homoeopathics contact Samantha for a consultation on 0403 194 226