Polycystic Ovarian Syndrome
by Lynn Dunning
(more about her after the article)
Polycystic ovarian syndrome is a very common disorder of the female endocrine system. In fact it is the most common hormonal illness in women of reproductive age. Irving Stein and Michael Leventhal first identified this disorder in 1935. Thus, originally the illness was called Stein-Leventhal disease. The doctors recorded the cases of seven obese, infertile, hirsute women with cysts on their ovaries who became pregnant and began menstruating after wedge resections were performed on them. They described these women and their “new disease” in the American Journal of Obstetrics and Gynecology (reference 1, after the article).1935 was the first time that all the symptoms were put together to create a definitive clinical picture, although before this a reference to “sclerocystic” changes of the ovary was reported in a French manuscript (2). The name was later changed to polycystic ovarian syndrome to reflect the common symptom of cystic ovaries present in many women with this condition.
There are numerous symptoms associated with this illness. However, according to a survey conducted in 1993 the most common symptoms of the illness are:
amenorrhea (no periods),
hirsutism (excess facial or body hair),
obesity (but thin women can also have PCOS; read below)
Since then it has been revealed that 40-80 percent of those with PCOS have insulin resistance and that 40 percent of patients develop diabetes by the age of 40 (4). (Insulin resistance will be explained in detail later in this article).
Other common symptoms are
male pattern hair-loss,
PMS for long period of time and
If left untreated serious complications can arise leading to diabetes, heart disease, hypertension, endometrial hyperplasia and endometrial cancer. Though the list of symptoms and problems associated with this disease may be frightening, the disease is treatable. Unfortunately however, it is not curable.
According to renowned PCOS expert Samuel Thatcher, “at least 20 percent and possibly as many as 70 percent of individuals with PCOS also have a disorder of insulin secretion or glucose metabolism” (5) (2000, p.145). The connection between insulin resistance and PCOS was not made until relatively recently, and in fact it is only now that many physicians are beginning to recognise that there is a relationship between the two. In fact, it was only in the 1980’s that Chang and Givens first published reports of a connection between I.R. (insulin resistance) and PCOS. Their work was later elaborated on by Dunaif in 1989.
Insulin resistance is a rather complicated phenomenon. I will provide a simplified explanation of it in this article to aid readers who are unaware of this condition. Insulin is a very important hormone in the human body. Too much or too little of this hormone leads to major health problems. Insulin is the body’s fat storage hormone and governs appetite, satiety and blood sugar levels. When a person eats, the pancreas releases insulin and the insulin then pushes glucose from the consumed food into the cells. Any excess glucose is stored in the fat cells. When a person suffers from insulin resistance glucose cannot enter cells. After many attempts insulin finally succeeds in getting some glucose into some cells and the excess is stored in fat cells. Since women with PCOS are usually insulin resistant their bodies therefore store more fat than healthy people’s bodies do. In a healthy person most of the glucose enters the muscle cells and only a small amount goes to the fat cells. This process is directly reversed in those with PCOS and insulin resistance. Insulin resistance also occurs in thin women, as does PCOS. According to Thatcher (2000), thin women with PCOS may even have a more severe form of PCOS, with more entrenched I.R. and infertility.
Hypoglycaemia also often occurs in people with insulin resistance. Hypoglycaemia simply means low blood sugar levels and can cause symptoms such as fatigue, dizziness, shaking, perspiration and intense sugar cravings. Those suffering from I.R. are vulnerable to bouts of hypoglycaemia due to the constant fluctuations in their blood sugar levels. Obviously, insulin resistance is a problem in and for itself, but if left unchecked it can lead to diabetes. One theory asserts that insulin resistance leads to type 2 diabetes because the pancreas becomes exhausted at pushing out large amounts of insulin and eventually stops. Thus, diabetes results.
Since insulin levels are so important in controlling weight, blood sugar and satiety and have a “knock-on” effect on other hormones such as testosterone, it is vitally important that insulin levels are kept at a steady level. Many women find that following a low glycemic index diet keeps these insulin levels “in check” and consequently their symptoms improve. A holistic method for treating PCOS and insulin resistance is covered below.
Diagnosing PCOS can be tricky and requires a comprehensive evaluation of the patient and her symptoms. A clinical history, various hormone tests and perhaps an ultrasound should be taken. Note that an ultrasound is not essential for diagnosing PCOS since the presence or lack thereof cysts does not necessarily indicate or preclude PCOS.
According to http://www.inciid.org a good screening panel would include:
Fasting comprehensive biochemical and lipid panel
2-hour Glucose Tolerance Test with insulin levels
LH: FSH ratio
There tends to be various hormonal abnormalities associated with PCOS. Often, cholesterol and triglyceride levels are raised and insulin resistance is evident. Also, many women with PCOS tend to have an abnormal LH: FSH (luteinizing hormone: follicle stimulating hormone) ratio. Instead of the ratio being 1:1 the LH level is substantially higher so that the ratio between the two becomes unequal. In general a ratio of over 3:1 indicates PCOS. Raised levels of androgens (such as DHEAS and androstenedione) are also usually present, often leading to a lower than normal level of SHBG. Prolactin levels may be raised, but this is not a very common facet of the syndrome, although some women with PCOS also suffer from hyperprolactinemia. Finally, a thyroid test should be undertaken so as to see if the patient is actually suffering from a thyroid disorder rather than PCOS. It is imperative that all of the above hormone levels are measured so as to exclude other disorders. PCOS itself is considered to be a diagnosis of exclusion, in that it can only be diagnosed when all other possibilities have been eliminated.
Nearly seventy years past the first report of the illness in a medical journal PCOS remains somewhat of a mystery. Within the past 10 years great strides have been made regarding treatments and the root causes of the disorder, although it still commonly goes undiagnosed in women for many years. There are varied reasons for this lack of diagnosis. Firstly, women do not always report their symptoms to their doctors, feeling embarrassed by symptoms such as facial hair. More importantly, most women do not “connect the dots,” so to speak, and realise for example that their irregular cycles are related to their weight problem. Another reason why the illness goes undiagnosed for long periods of time may be attributed to the fact that many doctors are simply uneducated and uninformed about the syndrome. So, they may attribute irregular cycles as being “natural” or tell their obese patients to stop overeating.
Another problem is the over-reliance on hormone levels to diagnose the condition. This poses a problem for methodological reasons, namely that lab tests are inaccurate if taken at the wrong time, (too late or early in the cycle, late in the evening), or if not taken properly (the patient is not in a fasting state). Also, there is some suggestion that normal lab values may be set too high since so many undiagnosed PCOS women are included in the normal range. Finally, the name of the illness can actually mislead doctors. This is because women who present with all the symptoms, but without the cystic ovaries, are often told they do not have the condition since they do not have the cysts. Many otherwise informed doctors do not realise that it is possible to have PCOS without having cysts on the ovaries. Researchers in the field of PCOS have discussed changing the name of the illness for this very reason.
Another more controversial reason why the disorder goes undiagnosed may be due to prejudice. There are two components to stigma/prejudice: visibility and controllability. Therefore people are judged more harshly if their stigma (in this case obesity) is visible and perceived to be controllable. Unfortunately, obesity fits into both those categories. One author has dubbed stigma against the obese as being the last socially acceptable stigma left and he may be right. Doctors are unfortunately not immune to this type of prejudice and as a result may overlook a patient’s obvious PCOS symptoms simply because she is overweight. Recent studies have clearly demonstrated that the medical profession can be just as prejudiced in this matter (6). They may tell their patient to lose weight or stop overeating as if it is purely her fault. What results from this is that a person does not receive the diagnosis she needs that would enable her to lose the weight that may indeed compromise her health.
PCOS is best approached in a holistic way, covering diet, exercise, herbs, nutrients, stress relief, proper sleep and relaxation although there are many conventional treatments for the disorder. Listed below are the conventional treatments for the most common symptoms:
1 Oligomenorrhea (irregular periods) and Amenorrhea (no periods)
The conventional treatments for this are the birth-control pill – the Pill – (the dangers of which are covered below) and Provera. Provera is a synthetic progestin that matures the womb lining, so that when it is withdrawn a period occurs. There are several side effects to both the Pill and Provera, however. The lists of side effects from the Pill are too numerous to list and taking Provera can result in severe PMS.
It is imperative that women have a period at least every three months. If women go longer than this without bleeding, their risk of endometrial hyperplasia and cancer increases greatly.
I do not favour the use of the Pill for treating PCOS. Mainly, this is due to the evidence that taking the Pill can worsen insulin resistance (7), especially if the Pill used is Dian 35 (Dianette, in Europe) which contains the steroid-like component cyperterone acetate (8). There is much debate about this issue, however, especially with a recent study stating that the Pill does not contribute to insulin resistance, and in fact keeps insulin levels steady (9). The fact that this study was conducted on women without PCOS may preclude these results being generalised to the PCOS population, however. More information on the pros and cons of taking the Pill can be found at http://nichollsvi.tripod.com/qbcp.html. Another reason I am against the use of the Pill is that many doctors will prescribe the Pill and then not bother treating I.R. or other symptoms, in effect masking them. This is not a good strategy as many women with PCOS find their symptoms worsen after coming off the Pill since it does not treat the root cause of the problem in any real way. Finally, the Pill has numerous side effects which women with PCOS do not need to contend with on top of symptoms they already have.
Anti_ androgens such as Spiroctalene and Flutamide are used. They are useful for relieving both the symptoms of hirsutism and also of acne. However, they cause serious birth defects so the Pill must be taken with them. Since the Pill can be used to help treat both these conditions and this medicine is stronger, it may make sense to try the Pill on its own first. A new prescription cream Vaniqua can also be used on the face. This cream slows the rate of facial hair regrowth greatly.
Laser treatment and electrolysis have also been successfully used. These treatments may be painful and are costly, however.
Acne sufferers may first be offered pills such as Yasmin or Dian 35 to help with their acne. Yasmin seems to work quite well for PCOS suffers, but as already described Dian 35 (Dianette, in Europe) is not a good choice. Other acne treatments offered are antibiotics that can cause gastrointestinal side effects, and topical agents such as benzyl peroxide, salicylic acid and Tretinoin and Roaccutane for severe cases.
If one is referred to a dietician she may be lucky or unlucky in terms of what diet tshe is prescribed. Nutritionists educated about PCOS will prescribe a diabetic diet complete with natural fats, adequate protein, large amounts of vegetables and small amounts of fruit and whole grains. However, often patients will simply receive outdated information from their doctors telling them to eat less or if referred to a nutritionist will be told to eat a low calorie, low fat diet. The patient may lose weight but they will not improve their health and will most likely feel miserable.
This is a vast topic. However, I will delineate the basic treatments offered. Usually women are offered Clomid to force their body to ovulate. However, this can cause severe PMS and can only be used for six cycles. Women will then be offered gonadotropin injections to stimulate their eggs. If this is unsuccessful more invasive procedures such as GIFT and IVF follow. Detailed comprehensive information can be found at www.inciid.org or www.resolve.org .
Nutrition: I am of the opinion that since PCOS is a chronic illness it is best treated holistically. A patient should concentrate on good nutrition first and foremost. There are several excellent books on nutrition available, but the best for those that suffer from PCOS are; “The Schwartzbein Principle” by Diana Schwartzbein, “The Diet Cure” by Julia Ross and “The PCOS Diet Book” by Colette Harris and Theresa Francis-Cheung. These books concentrate on improving health rather than weight loss and as such are much better approaches to weight loss for women with PCOS.
In essence the PCOS sufferer should ensure her diet is comprised of good quality protein such as meat, fish, (an excellent source of omega 3 fatty acids, which are so important for those with PCOS), poultry, nuts, seeds, eggs and cheeses. Good vegetarian protein sources are quorn, dairy, nuts, seeds and a small amount of beans and the less fermented soy products such as miso or tempeh. Soy is not the miracle food it is purported to be. In fact there are several health problems associated with the over consumption of soy (http://www.mercola.com/article/soy/avoid_soy.htm and http://www.holdthetoast.com/archive/010411.html).
The diet should also include good quality fats such as cold pressed oils. It is imperative that trans fatty acids and hydrogenated fats be avoided since they raise cholesterol and are carcinogenic. Finally, the right amount of carbohydrates according to activity level, health, insulin status and weight should be consumed in the form of vegetables, whole grains and a small amount of fruit.
Refined carbohydrates, white flour, sugar and caffeine should be greatly reduced and if possible eliminated from the diet. Also, if possible, choose organic foods.
Exercise: There is abundant evidence that exercise improves the body’s use of insulin. Those with PCOS should try to concentrate on resistance rather than cardiovascular exercise. This is because resistance exercise (i.e., weight training, swimming, yoga, pilates) builds muscle and thus increases the body’s insulin sensitivity. According to Schwartzbein (10), too much cardiovascular exercise raises adrenaline and cortisol levels and consequently raises insulin levels.
Even a simple walk most nights may be of help. Exercises such as yoga are particularly recommended because they relieve stress and work the muscles as well as targeting health problems.
Herbs: Since this condition is chronic, herbs can help greatly due to the fact that they are much gentler on the body than synthetic drugs. They also have fewer side effects and many can be used for sustained periods of time. There are numerous herbs that can be used for various symptoms of PCOS. Therefore, the most commonly used herbs are outlined below. NOTE: I have had great success using herbs, but have found only the tincture forms effective. Tablets are synthesised in a different way and do not work at all for me. I have conversed with other women who have found the same.
Agnus Castus (also referred to as vitex or chasteberry): This seems to be the herb most commonly used by women with PCOS. Vitex has a direct effect on the pituitary gland; the gland involved in regulating hormone production. It seems to increase the level of LH, although the studies that have shown this have been conducted in women without PCOS. Therefore, this does not mean it increases LH levels in women with PCOS. The fact that it works so well in women with PCOS lends great support to David Hoffman’s (11) assertion that vitex is an adaptive herb that does whatever the body needs it to do. It seems to restore progesterone to a normal level , which is helpful for those with low progesterone levels. Low progesterone levels can cause miscarriage so vitex can help to prevent this. It is also used for irregular menstruation, amenorrhea and PMS.
Donq Quai: This is actually a Chinese herb but it is widely available in Western health food stores. It is one of the best women’s herbs and has been dubbed “the female ginseng” (12). Similar to vitex, it can be used for long periods of time because it is a tonic herb. It nourishes the liver and endocrine system and is useful for irregular menstruation, PMS, period pain and menopausal symptoms. It is a phytoestrogenic herb.
Black Cohosh: Black cohosh is a uterine tonic herb and exhibits an oestrogenic effect. It is widely used in menopausal formulas but is valuable for treating amenorrhea, irregular menstruation and PMS. This herb can also lower blood pressure.
Saw Palmetto: Saw palmetto is traditionally used to treat male prostate enlargement. However, since it is an anti-androgen many women with PCOS use it to treat hirsutism and acne. It has a side effect of increasing breast size in some and consequently is used in breast enhancing herbal formulas to increase cup size. However, it does not always have this effect.
Evening Primrose: a widely popular supplement taken by many women for PMS, fibrocystic breast disease and to improve skin quality. It can also help with irregular cycles. It is rich in G.L.A and linolenic acid; essential fatty acids which the body requires to regulate hormones. Evening Primrose oil also helps with heart disease, cholesterol and blood pressure.
Progesterone cream: This cream has been widely popularised by Dr. John Lee, who advocates the use of this cream for many female conditions such as menopause, PMS, fibrocystic breast disease, ovarian cysts and PCOS. It can be ordered from various companies on the Internet.
Supplements: Many women with PCOS find supplements very helpful in relieving various symptoms. Recommended supplements for PCOS are: the B complex, a good quality multivitamin with chelated minerals, GTF chromium and fish oils. To this basic regime other supplements can be added depending on various symptoms.
Awareness of PCOS is increasing amongst the medical profession and the general public so that soon there may be less delay in diagnosis. Also, metformin rather than just the Pill is prescribed more and more to the PCOS patient, thereby treating rather then just masking the disorder. Finally, more nutritionists are becoming aware of the damage refined carbohydrates, sugar and hydrogenated fats wreak on the body. Overall, the outlook for women with PCOS is getting better and better by the day.
A diagnosis of PCOS may seem overwhelming at first, but there is much support and help available. Visit http://www.soulcysters.com [a wonderful name] and http://www.pcosupport.org to get in contact with other sufferers and inform yourself of the latest treatments. PCOS is not curable, but it is a disease that is treatable. Treating a chronic disorder takes time and patience, but good health can indeed be restored if one is prepared to work for it.
Article copyright 2003 Lynn Dunning
Lynn Dunning graduated from University College Dublin, Ireland, in 2002 with a B.A. in psychology. She set up her own Web site for Irish women with PCOS in 2001 (http://www.geocities.com/pcosireland) and moderates two other PCOS Web sites also. Having finally got her own PCOS under control she aims to raise awareness both of the condition and how it can be healed.
1 Stein, l.F; & Leventhal, M.L. (1935). Amenorrhea associated with bilateral polycystic ovaries. American Journal of Obstetrics and Gynecology, 29, 181-191
2 Thatcher, S. ( 2000). Polycystic Ovary Syndrome: The Hidden Epidemic. Indianapolis: Perspectives Press
3 Gilling-Smith, C; & Franks, S.(1993). Polycystic Ovary Syndrome. Repord Medical Review 2, 15-32
4 & 5 Thatcher, S. (2000). Polycystic Ovary Syndrome: The Hidden Epidemic. Indianapolis: Perspectives Press
6 Stunkard, AJ. & Wadden, T.A.( 1992) Psychological aspects of human obesity. Human Obesity: General Aspects, 352-358
7 Watanabe, R.M; Azen, C.G; Roy, S; Perlman, J.A; & Bergman, R.N. (1994). Defects in carbohydrate metabolism in oral contraceptive users without apparent metabolic risk factors. Journal of Clinical Endocrinology & Metabolism, Nov: 79 (5), 1277 _ 1283
8 Browder, S.E. ( 2001). The Power, 166. New York: John Wiley & Sons
9 Kim, C; Siscovick, D.S; Sidney, S; Lewis, C.E; Kiefe, C.L; & Koepsell, T.D. (2002). Diabetes Care, 25 (6), 1027 – 1032
10 Schwartzbein, D; & Marilyn Brown (2003). The Schwartzbein Principle 2: The Transition. Florida: Health Communications Inc
11 Hoffman, D. (1983). The Holistic Herbal. Scotland: Findhorn Press
12 Gladstar, R. ( 1993). Herbal Healing for Women. New York: Fireside