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  Polycystic Ovary Syndrome (PCOS)  
 
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Signs, symptoms and indicators | Conditions that suggest it | Contributing risk factors | Other conditions that may be present | It can lead to... | Recommendations

 

Polycystic ovary syndrome (PCOS), previously known as Stein-Leventhal syndrome, is a disorder in which numerous benign cysts form on the ovaries under a thick, white covering. It is most common in women under 30 years old. The ovaries are the female reproductive organs that contain and release eggs. They also produce the female hormones estrogen and progesterone. Ovarian cysts are fluid-filled sacs that result from ovulation cycles. Many ovarian cysts disappear without treatment. The most common are just enlargements of the normal egg follicles.

Between 5 and 30% of women have some characteristic of PCOS. This is one of the most common hormonal abnormalities in women of reproductive age and is a leading cause of infertility. Often in PCOS patients, periods start at the usual age of 12-13, while some start menstruating earlier. Interestingly, there appears to be variabilities of PCOS clinical manifestations among races. For example, obesity and hirsutism are not prominent among Japanese people, whereas they are much more common among Caucasians.

How does it occur?
Polycystic ovary disease is due to an abnormal production of two of the hormones produced by the pituitary gland in the brain. These two hormones are LH (luteinizing hormone) and FSH (follicle-stimulating hormone). Imbalance of these hormones prevents the ovaries from releasing an egg each month. It also results in an increased production of the male hormone testosterone by the ovaries.

How is it diagnosed?
Your doctor diagnoses polycystic ovary disease with tests and exams including your medical history, a physical exam, blood tests to check hormone levels and an ultrasound. Because it is a syndrome, PCOS includes a set of symptoms. Women with PCOS can suffer from any combinations of the usual symptoms. Some women experience only one of these symptoms, while other women experience all of them. The severity of PCOS symptoms can vary widely from woman to woman.

How is it treated?
The method of treatment depends on the severity of the symptoms and whether you are trying to get pregnant. If you are not trying to conceive, you can be treated with hormones, including the birth control pill. Hormones and birth control pills will give regular menstrual cycles and may reduce abnormal hair growth. They also reduce the risk of developing endometrial hyperplasia, a condition that can become uterine cancer. If you are trying to become pregnant, your health care provider may prescribe fertility drugs, but it can be a long and complicated treatment.

In rare cases a wedge of ovarian tissue may be surgically removed or destroyed. This usually results in regular menstrual cycles for a while. For excess body and facial hair, your health care provider may recommend electrolysis.

It is desirable to have a period at least at intervals, though not necessarily monthly. Hormonal treatment, including the use of natural progesterone, can achieve this where required. The natural approach to PCOS should involve using all of the appropriate therapies at the same time and may require many months before improvement is seen.

The conventional treatment of PCOS is directed primarily at the problems of hirsutism, menstrual irregularity and infertility. Treatment modalities for hirsutism include ovarian and adrenal suppression, anti-androgen therapy and local hair removal measures. Oral contraceptives are simple and relatively safe method of ovarian suppression, in addition the estrogen component increases the sex hormone binding globulin (SHBG) with a resultant decrease in free testosterone. When DHEA-S levels are elevated, the addition of dexamethasone may be helpful. Spironolactone is the preferred anti-androgenic compound. It competitively inhibits intracellular dihydrotestosterone receptors within the hair follicles. Both cimetidine and cyproheptadine (a serotonin and histamine antagonist) have weak anti-androgenic effects.
 

 
 

Signs, symptoms & indicators of Polycystic Ovary Syndrome (PCOS):
 
 
Symptoms - Reproductive - Female Cycle  Irregular menstrual cycles
  Having light/having heavy periods
 
 

Conditions that suggest Polycystic Ovary Syndrome (PCOS):
 
 
Hormones  Elevated DHEA
 In PCOS, there are often increased circulatory levels of androgens produced by both the ovaries and the adrenal glands. If they are elevated, serum testosterone levels are usually between 70-120ng/dl, and androstenedione levels are usually between 3 and 5ng/ml. Also, about half the women with this syndrome have elevated DHEA-S.

  Hirsutism
 It has been traditional to divide patients with hirsutism into those with no elevation of serum androgen levels and no other clinical features ('idiopathic hirsutism') and those with an identifiable endocrine imbalance (most commonly PCOS or rarely other causes). However in recent years it has become apparent that most patients with 'idiopathic hirsutism' have some radiological or biochemical evidence of PCOS on more detailed investigation.

The presence or absence of hirsutism depends on whether these androgens are converted peripherally by 5 alpha reductase to the more potent androgen DHT dihydrotestosterone and 3 alpha diol-G as reflected by increased levels of 3 alpha-diol-G. Therefore, it is skin 5-alpha reductase activity that largely determine the presence or absence of hirsutism.

  Elevated Testosterone Level, Female
  Elevated Insulin Levels
 Researchers found that 75% of women studied with PCOS were hyperinsulinemic. [Fertil Steril 2000;73(1): pp.150-156, J Clin Endocrinol Metab 1999;84(6): pp.1897-1899]

Insulin resistance is a unique feature of PCOS and not of hyperandrogenic states in general. PCOS is an important risk factor for the development of type 2 diabetes mellitus in women. It is estimated that approximately 10% of diabetes in premenopausal women is PCOS related.

Metabolic

  Problem Caused By Being Overweight

Organ Health

  Diabetes Type II
 By the age of 40, up to 40% of women with PCOS will have Type II diabetes or impaired glucose tolerance.

Risks

  Increased Risk of Coronary Disease / Heart Attack
 Women with the PCOS have a five to seven times higher risk of myocardial infarction and ischemic heart disease than other women. Surprisingly, the increased risk was found to be independent of obesity, supporting the argument that insulin resistance alone is important in determining cardiovascular risk. [Fertil Steril 2000;73(1): pp.150-156, J Clin Endocrinol Metab 1999;84(6): pp.1897-1899]

Skin-Hair-Nails

  Adult Acne
 Among women with resistant acne (acne not responding to conventional treatments), PCOS is very common.

  Adolescent Acne
  Female Hair Loss

Uro-Genital

  Amenorrhea
 In many women with polycystic ovaries, menstruation begins at the normal age. After a year or two of regular menstruation, the periods become highly irregular and then infrequent.

  Female Infertility
 Impaired fertility is a prominent feature of PCOS. This is believed to result from elevated insulin levels that stimulate excess androgen production by the ovaries. The androgens cause premature follicular wasting which causes inconsistent or absent ovulation, which is associated with infertility.
 
 

Risk factors for Polycystic Ovary Syndrome (PCOS):
 
 
Childhood  Early puberty onset
 Some research suggests that girls who begin to develop pubic hair early (usually before the age of eight, a condition known as premature pubarche) have been found to have many of the signs and symptoms of PCOS. When girls with premature pubarche have been followed throughout the rest of puberty they have been found to develop excess testosterone production and irregular periods consistent with PCOS. Thus premature pubarche may be an early form of PCOS.

Symptoms - Reproductive - Female Cycle

Counter-indicators:
  Hysterectomy with one ovary or hysterectomy with both ovaries
 
 

Polycystic Ovary Syndrome (PCOS) suggests the following may be present:
 
 
Hormones  Elevated Insulin Levels
 Researchers found that 75% of women studied with PCOS were hyperinsulinemic. [Fertil Steril 2000;73(1): pp.150-156, J Clin Endocrinol Metab 1999;84(6): pp.1897-1899]

Insulin resistance is a unique feature of PCOS and not of hyperandrogenic states in general. PCOS is an important risk factor for the development of type 2 diabetes mellitus in women. It is estimated that approximately 10% of diabetes in premenopausal women is PCOS related.

  Low SHBG
 Low levels are often found in cases of polycystic ovary syndrome. SHBG is low in about 50% of cases.
 
 

Polycystic Ovary Syndrome (PCOS) can lead to:
 
 
Risks  Increased Risk of Endometrial Cancer
 Polycystic ovary syndrome is associated not only with infertility but also with a higher risk for endometrial (uterine) cancer.

Uro-Genital

  Female Infertility
 Impaired fertility is a prominent feature of PCOS. This is believed to result from elevated insulin levels that stimulate excess androgen production by the ovaries. The androgens cause premature follicular wasting which causes inconsistent or absent ovulation, which is associated with infertility.
 
 

Recommendations for Polycystic Ovary Syndrome (PCOS):
 
 
Animal-based  Glandular / Live Cell Therapy
 A protomorphogen extract from Standard Process called Symplex F is a mixture of specially processed glandular extracts from the four organs that make up the so-called pituitary axis - the pituitary, thyroid, adrenal glands and the ovaries. One to two tablets per day for a year can help normalize the function of these important organs.

Botanical

  Licorice Root (Glycyrrhiza glabra)
 In a 1982 trial, eight anovulatory infertile women with elevated testosterone were investigated for lowering serum testosterone levels and inducing regular ovulation by a formula containing equal parts of peony root (Paeonia lactiflora) and licorice root (Glycyrrhiza glabra). Serum testosterone levels were significantly lowered in seven patients by doses of 5-10 grams of the combination daily for 2-8 weeks. Six of seven patients ovulated regularly and two of six patients conceived (Yaginuma et al.) In a similar trial in 1988, a significant reduction of circulating testosterone occurred in 18 of 20 female subjects with PCOS (Takahashi et al.). Five of the 18 became pregnant. In the above trials, it was not established which plant or plant constituents altered the testosterone levels. In 1991, researchers performed in vitro tests of the effects of several plant constituents from peony and licorice on rat ovary cells, and suggested that glycyrrhetic acid, a metabolite of glycyrrhizin in humans, inhibits the conversion of androstenedione to testosterone. Armanini et al. suggested that glycyrrhizin, or its metabolites, act on the enzymes that convert 17-hydroxy-progesterone to androstenedione, effectively lowering testosterone.

For example, equal parts of Mediherb extracts can be mixed together and given at a dose of 1/2 to 1 teaspoon of the mixture, 2-3 times per day. Treatment can continue for six months with a break of at least one week every 4-6 weeks.

Diet

  Sugars Avoidance / Reduction
 A high sugar diet causes obesity with further insulin resistance and aggravation of PCOS. According to Jerilyn Prior, M.D., the increased insulin from sugar consumption stimulates androgen receptors on the outside of the ovary, causing a failure of ovulation and the typical PCOS symptoms of hirsutism and acne.

  Weight Loss
 Weight reduction can not only reverse testosterone and luteinizing hormone abnormalities and infertility seen with PCOS, but also improve glucose, insulin and lipid profiles. Obesity is an important feature with regard to hirsutism because it is associated with decreased sex hormone binding globulin (SHBG). This results in increased levels of unbound testosterone and contributes to the acne and hair growth seen in PCOS.

A study looked at 38 obese PCOS patients and showed that weight loss could ease effects of polycystic ovary syndrome (PCOS). Losing weight appears to improve egg release and ovulation function in obese patients, leading to an increased chance of pregnancy. Nearly 70 percent of women diagnosed with PCOS are obese. Researchers note that dealing with PCOS becomes more complicated as the number of obese patients increases, which reflects a nationwide trend of obesity on the rise.

With a control group set aside for comparison, the remaining patients underwent a 24-week diet and exercise program. Those in the program were divided into two groups. Group one used the diabetes drug, metformin, during the study; Group two participants did not. Metformin makes the body's tissues more sensitive to insulin and is one of the most common OHAs, or oral hypoglycemic agent, on the market.

At the conclusion of the 24 weeks, women in both diet and exercise groups showed significant reduction in body weight. Control group participants did not. Also, researchers determined patients using metformin more easily met their weight loss goals.

When it came to ovulation, women who lost weight were nine times more likely to experience regular cycles than those in the control group. Those that lost weight and used metformin were 16 times more likely to ovulate on a normal basis than women who did not lose weight.

Researchers concluded that ovulation restoration can be accomplished with modest weight loss, as well as metformin therapy. While researchers admitted that the data is preliminary and follow-up studies need to be done, they specifically added that physicians should take note of the study. [Yahoo! News August 26, 2004]

  Grain-free / Low Starch Diet
 When breads and cereals are digested, it leads to an increased amount of sugar and allows the body to produce high levels of insulin and insulin-like growth factor (IGF-1). Elevated insulin levels lead to an excess of male hormones. When women with polycystic ovary syndrome, a condition that causes an excess of insulin, were treated with the insulin-reducing drug metformin, acne was improved.

Drug

  Conventional Drugs / Information
 Metformin is used to reduce insulin resistance. Treatment with this drug frequently leads to a return of ovulation. Other therapies include clomiphene citrate (to induce ovulation), spironolactone (an antiandrogen), and oral contraceptives (to treat menstual irregularities and hirsutism).

Habits

  Aerobic Exercise

Hormone

  Progesterone
 Many women with PCOS have had success using progesterone cream to help produce regular periods.

Lab Tests/Rule-Outs

  Test / Monitor Hormone levels
 The most worrisome consideration in PCOS is the presence of an androgen-producing neoplasm. It is for this reason that a measurement of total testosterone and DHEA is recommended.

Mineral

  Chromium
 Chromium potentiates the action of insulin. In 3 women with PCOS, 1,000mcg of chromium per day for a duration of 2 months improved insulin sensitivity by 30%. [Fertil Steril. 2006;80: pp. S45-S46] In a separate study with 5 women, the improvement was 38%. [Fertil Steril. 2006;86: pp.243-246]

Nutrient

  Inositol
 D-chiro-inositol, a relative of common inositol (a B vitamin), is found in small concentrations in the human body and in some foods. It is a compound that has been reported to affect the action of insulin.

There is evidence that the insulin resistance seen in women with PCOS is due in part to a deficiency of D-chiro-inositol or to a defect in its utilization in the tissues. If these abnormalities can be reversed by supplementation with D-chiro-inositol, then this compound might be beneficial for women with PCOS. To test that possibility, 44 obese women with PCOS were randomly assigned to receive, in double-blind fashion, D-chiro-inositol (1,200 mg once a day) or placebo for eight weeks.

Supplementation with D-chiro-inositol resulted in an improvement in insulin resistance and a 55% reduction in testosterone levels compared to the placebo group. Significantly more women ovulated in the D-chiro-inositol group than in the placebo group (86% vs. 27%). D-chiro-inositol supplementation decreased testosterone levels and improved ovulatory function, presumably by enhancing the action of insulin. [Diabetes Care 2006;29: pp.300-305] [Engl J Med. 1999 Apr 29;340(17): pp.1314-20]

However, it is very difficult to find D-chiro inositol and even if you can find it, it can cost $145 for a 60-capsule bottle. It recently came to our attention that, www.mypcos.info/1. is offering it at a significantly reduced rate, and anyone can contact them directly.

Pinitol (3-O-methyl- D-chiro-inositol) is an inositol compound with a chemical structure and biochemical actions similar to D-chiro-inositol. Unlike D-chiro inositol, pinitol is conveniently available as a nutritional supplement. But like D-chiro-inositol, pinitol is relatively expensive.

Vitamins

  Vitamin D
 Vitamin D deficiency appears to occur frequently in women with PCOS and may be a contributing factor to some ot the biochemical abnormalities seen in this condition. Vitamin D also improves glucose tolerance, insulin secretion, and insulin sensitivity in those with diabetes. This improved glucose tolerance may be the mechanism for producing benefits in PCOS. A reasonable dosage is 800 to 1,200 IU per day for several months.
 
 


KEY
Weak or unproven link
Strong or generally accepted link
Proven definite or direct link
Strongly counter-indicative
May do some good
Likely to help
Highly recommended







GLOSSARY

Acne:  A chronic skin disorder due to inflammation of hair follicles and sebaceous glands (secretion glands in the skin).

Androgen:  Any steroid hormone that increases male characteristics.

Benign:  Literally: innocent; not malignant. Often used to refer to cells that are not cancerous.

Cancer:  Refers to the various types of malignant neoplasms that contain cells growing out of control and invading adjacent tissues, which may metastasize to distant tissues.

Cardiovascular:  Pertaining to the heart and blood vessels.

Cysts:  A closed pocket or pouch of tissue; a cyst may form within any tissue in the body and can be filled with air, fluid, pus, or other material. Cysts within the lung generally are air filled, while cysts involving the lymph system or kidneys are fluid filled. Cysts under the skin are benign, extremely common, movable lumps. These may develop as a result of infection, clogging of sebaceous glands, developmental abnormalities or around foreign bodies.

DHEA:  Dehydroepiandrosterone (DHEA) is a steroid produced by the adrenal glands and is the most abundant one found in humans. DHEA may be transformed into testosterone, estrogen or other steroids. It is found in the body as DHEA or in the sulfated form known as DHEA-S. One form is converted into the other as needed.

DHT:  Dihydrotestosterone - a highly active form of testosterone, which influences many aspects of manly behavior, from sex drive to aggression. The conversion from testosterone to DHT is driven by an enzyme called 5-alpha reductase, which is produced in the prostate, various adrenal glands, and the scalp.

Diabetes Mellitus:  A disease with increased blood glucose levels due to lack or ineffectiveness of insulin. Diabetes is found in two forms; insulin-dependent diabetes (juvenile-onset) and non-insulin-dependent (adult-onset). Symptoms include increased thirst; increased urination; weight loss in spite of increased appetite; fatigue; nausea; vomiting; frequent infections including bladder, vaginal, and skin; blurred vision; impotence in men; bad breath; cessation of menses; diminished skin fullness. Other symptoms include bleeding gums; ear noise/buzzing; diarrhea; depression; confusion.

Estrogen:  One of the female sex hormones produced by the ovaries.

Glucose:  A sugar that is the simplest form of carbohydrate. It is commonly referred to as blood sugar. The body breaks down carbohydrates in foods into glucose, which serves as the primary fuel for the muscles and the brain.

Histamine:  A chemical in the body tissues, produced by the breakdown of histidine. It is released in allergic reactions and causes widening of capillaries, decreased blood pressure, increased release of gastric juice, fluid leakage forming itchy skin and hives, and tightening of smooth muscles of the bronchial tube and uterus.

Hormones:  Chemical substances secreted by a variety of body organs that are carried by the bloodstream and usually influence cells some distance from the source of production. Hormones signal certain enzymes to perform their functions and, in this way, regulate such body functions as blood sugar levels, insulin levels, the menstrual cycle, and growth. These can be prescription, over-the-counter, synthetic or natural agents. Examples include adrenal hormones such as corticosteroids and aldosterone; glucagon, growth hormone, insulin, testosterone, estrogens, progestins, progesterone, DHEA, melatonin, and thyroid hormones such as thyroxine and calcitonin.

Idiopathic:  Arising spontaneously or from an obscure or unknown cause.

Insulin:  A hormone secreted by the pancreas in response to elevated blood glucose levels. Insulin stimulates the liver, muscles, and fat cells to remove glucose from the blood for use or storage.

Ischemia:  Localized tissue anemia due to obstruction of the inflow of arterial blood.

Luteinizing Hormone:  Anterior pituitary hormone stimulating estrogen production by the ovary; promoting formation of progesterone by the corpus luteum in women and stimulating testosterone release in men.

ng:  Nanogram: 0.000000001 or a billionth of a gram.

Ovarian Cysts:  These occur in two forms, namely "functional" and "organic". may not be present but can include pressure or pain in the abdomen, problems with urine flow or pain during sexual intercourse. Rarely, a very large cyst can become twisted and stop its own blood supply, possibly causing nausea, fever or severe abdominal pain. Functional ovarian cysts form part of the normal functioning of the ovary and are always benign. They may be either "follicular cysts", produced by all menstruating women every month and reaching up to 2-3cm in diameter before they rupture at ovulation, or "corpus luteum cysts", which appear after ovulation and may grow to produce "hemorrhagic cysts" if ovulation does not occur or is delayed. Rupture of such a cyst can sometimes cause painful ovulation or bleeding, which is often moderate and resolves by itself. Organic ovarian cysts may be benign or malignant and are not linked to the functioning of the ovary. They occur as either "dermoid cysts", which are benign tumors that may nevertheless recur on either ovary and contain elements derived from the skin (hairs, sebum, teeth), or other organic cysts.

Pituitary:  The pituitary gland is small and bean-shaped, located below the brain in the skull base very near the hypothalamus. Weighing less than one gram, the pituitary gland is often called the "master gland" since it controls the secretion of hormones by other endocrine glands.

Premenopause:  The period when women of childbearing age experience relatively normal reproductive function (including regular periods).

Serotonin:  A phenolic amine neurotransmitter (C10H12N2O) that is a powerful vasoconstrictor and is found especially in the brain, blood serum and gastric membranes of mammals. Considered essential for relaxation, sleep, and concentration.

Serum:  The cell-free fluid of the bloodstream. It appears in a test tube after the blood clots and is often used in expressions relating to the levels of certain compounds in the blood stream.

Testosterone:  The principal male sex hormone that induces and maintains the changes that take place in males at puberty. In men, the testicles continue to produce testosterone throughout life, though there is some decline with age. A naturally occurring androgenic hormone.