Essay On Polycystic Ovary Syndrome

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Read another article about PCOS, by Dr. Nelson Soucasaux
See the wax model of a woman's corpse used for teaching in 18th century Italy (not in this museum).


Polycystic Ovarian Syndrome

by Lynn Dunning
(more about her after the article)

Overview
Polycystic ovarian syndrome was first identified by Irving Stein and Michael Leventhal in 1935, and the condition was originally called Stein-Leventhal disease. The name was later changed to polycystic ovarian syndrome to reflect the common symptom of cystic ovaries present in many women with this condition. Currently, it is the most common hormonal illness in women of reproductive age.
Stein and Leventhal recorded the cases of seven obese, infertile, hirsute women with cysts on their ovaries who became pregnant and began menstruating after they underwent wedge resection surgery. They described these women and their "new disease" in the American Journal of Obstetrics and Gynecology. 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.

Symptoms
There are numerous symptoms associated with this illness. However, the most common ones are:
    •    Irregular periods
    •    Amenorrhea (lack of periods)
    •    Hirsutism (excess facial or body hair)
    •    Acne
    •    Obesity (It must be noted however that thin women can also have PCOS.)
    •    Infertility
    •    Insulin resistance (40-80% of those with PCOS have insulin resistance, and 40% will develop diabetes by the age of 40.)
    •    Estrogen dominance
Other common symptoms are:
    •    Male pattern hair-loss
    •    Depression
    •    Pelvic pain
    •    PMS
    •    Miscarriage
If left untreated, PCOS can increase the risk of diabetes, heart disease, hypertension (high blood pressure), eating disorders, endometrial hyperplasia and endometrial cancer. Though the list of symptoms and problems associated with this disease may be frightening, the disease is treatable.
Insulin resistance
According to renowned PCOS expert Dr Samuel Thatcher, "At least 20%, and possibly as many as 70% of individuals with PCOS also have a disorder of insulin secretion or glucose metabolism"(2000, page 145). The connection between insulin resistance and PCOS was not made until relatively recently however, and many physicians are only now beginning to recognise that there is a relationship between the two. Chang et al. first published reports of a connection between insulin resistance and PCOS in the 1980s. Their work was later elaborated on by Dunaif in 1989. This is all very recent in medical terms.
Insulin resistance is a rather complicated phenomenon. First, it is important to note that insulin is a very important hormone in the human body and too much or too little of it leads to problems.
Insulin governs appetite, satiety and blood sugar levels. It also appears to regulate fat accumulation on the body. When a person eats, the pancreas releases insulin and this 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 however, glucose cannot enter the cells. After many attempts, insulin finally manages to push some glucose into a few cells, but the excess is stored in fat cells. This lack of glucose in the cells leads to hunger, fatigue and weight gain. In an insulin sensitive person on the other hand, most of the glucose enters the muscle cells and only a small amount goes to the fat cells. It is important to note that insulin resistance also occurs in thin women, as does PCOS. Samuel Thatcher believes that thin women with PCOS may even have a more severe form of PCOS, with more entrenched insulin resistance and infertility.
Hypoglycaemia is also a common phenomenon in people with insulin resistance. Hypoglycaemia simply means low blood sugar levels (it can also refer to blood sugar levels that fall after a meal, rather than increasing as is normal). Low blood sugar can cause symptoms such as fatigue, dizziness, shaking, perspiration and intense sugar cravings. Those suffering from insulin resistance are vulnerable to bouts of hypoglycaemia due to the constant fluctuations in their blood sugar levels. Obviously, insulin resistance is a problem in and of itself, but if left unchecked it may lead to diabetes. 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/good carb diet keeps these insulin levels at an optimal level, and consequently their symptoms improve.
It is also important to note that it is normal and healthy to have high insulin levels directly after meals. Healthy people’s insulin levels peak after meals as insulin pushes glucose into their cells. Their insulin levels quickly come down though and are back to baseline within two hours after eating.

Estrogen dominance
Many women with PCOS are also estrogen dominant. The phrase estrogen dominance was first coined by Dr. John Lee. When a woman is in a state of estrogen dominance it means that her estrogen levels are not balanced. They are either too high and/or they are not in balance with progesterone levels. Progesterone levels may also be low.
estrogen is the hormone that thickens the endometrial (womb lining), matures the ovarian follicles, controls cervical fluid and helps maintain bones. Estrogen is necessary for fertility and regular periods. However, having high estrogen levels increases the risk of cancer. It also causes gynaecological problems and PMS.
In a normal menstrual cycle, estrogen and progesterone levels are low until mid cycle. After ovulation, estrogen levels are meant to be fairly low, but progesterone is supposed to be at its highest. Many women’s hormones no longer follow this healthy pattern. Unfortunately, our food and water supply have become contaminated with various chemicals over the past few decades, which have greatly affected sex hormone balance. Our food is also often wrapped in plastic, which is a known endocrine disruptor. This is because one component of plastic (BPA) is known to bind to estrogen receptors.
Therefore, it is very common for the menstrual cycle to be disrupted by these hormone imbalances. Even if a women has regular cycles, her hormones can still be imbalanced. Many women simply do not produce enough progesterone after they ovulate and their estrogen levels are also too high. Many doctors cite low progesterone or progesterone dominance as being the cause of PMS and painful periods.
It is also important to remember that even though estrogen levels tend to be low in pre menopausal and post menopausal women, the hormone still tends to be too high relative to progesterone at this time. This is because women are not ovulating after menopause and are thus only producing extremely small amounts of progesterone.
A large amount of women with PCOS have high estrogen levels. These high estrogen levels lead to large amounts of follicles being produced. Since many women with PCOS do not ovulate or have periods regularly, the levels of estrogen build up, since there is no progesterone to balance them.

Diagnosis
Diagnosing PCOS can be tricky and it 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 www.inciid.org, a good screening panel would include:
    •    Fasting comprehensive biochemical and lipid panel
    •    Two hour glucose tolerance test with insulin levels
    •    LH: FSH ratio
    •    Estrogen and progesterone seven days after ovulation, or Day 21 in a woman with a regular 28 day cycle
    •    DHEAS
    •    SHBG
    •    Androstenedione
    •    Prolactin
    •    Thyroid panel
There tends to be various hormonal abnormalities associated with PCOS. Often, cholesterol and triglyceride levels are raised  and insulin resistance is evident. Plus, many women with PCOS tend to have an abnormal LH: FSH (luteinising 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 sex hormone binding globulin. 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 full thyroid panel with FT4, FT3, RT3, anti- TPO and anti-TgAb should be taken in order to see if the patient is actually suffering from a thyroid disorder rather than PCOS. It is imperative that all of the above thyroid hormone levels are measured and not just a TSH. PCOS itself is considered to be a diagnosis of exclusion, in that it can only be diagnosed when all other possibilities have been eliminated.
Patients should also always get a copy of their lab tests, so that they can track their results over time.
Even though PCOS was first reported in a medical journal 77 years ago, it still remains somewhat of a mystery. Great strides have been made regarding treatments and the root causes of the disorder over the past 15 years, but 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, many doctors do not "connect the dots,", and realize that their patients’ irregular cycles are related to their weight problems, for example. Doctors also seem to be generally uneducated and uninformed about the syndrome.
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. In other words, if the normal lab range includes a lot of women with PCOS, then the lab range will be skewed towards ill health. Unfortunately, this is a common problem for almost all lab ranges and this is why informed patients and doctors tend to try to get their patients to a specific place within a lab range, i.e. they aim to get hormones into the optimal part of the range.
Finally, the name PCOS itself 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 if they do not have the cysts. Unfortunately, many otherwise informed doctors do not realize 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.
There is a more controversial reason why the disorder may go undiagnosed: prejudice. There are two components to stigma/prejudice: visibility and controllability. People tend to be judged more harshly if their stigma (in this case obesity) is visible and if it is perceived to be controllable. Unfortunately, obesity fits into both those categories. Kavic 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 they are overweight. Recent studies have clearly demonstrated that the medical profession can be just as prejudiced in this matter. Health professionals may tell their patient to lose weight or to stop overeating, as if it is purely their fault. As a result the patient is left to suffer. Ironically, the patient may have indeed lost weight if they had been treated properly for PCOS.

Treatments
PCOS is best approached in a holistic way, which should include: medication if appropriate, modified nutrition (this should not include any type of low calorie diet), exercise, herbs, nutritional supplements, stress relief, proper sleep and relaxation.
Listed below are the conventional treatments for the most common symptoms. Holistic treatment is covered in the next section.

Oligomenorrhea (irregular periods) and amenorrhea (no periods)
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. Therefore, women should work together with their doctor to induce regular menstruation.
The conventional treatments for period problems are the birth control pill and Provera. Provera is a synthetic progestin that matures the womb lining, which causes a “period” when the Provera is stopped. Technically this period is actually withdrawal bleeding; it is not a real period. Unfortunately, both the pill and Provera have many side effects and long terms risks. It is also important to note that Provera is NOT progesterone. It is a synthetic progestin compound that differs from the progesterone that the body naturally makes. It can cause a variety of side effects and is known to cause severe PMS.
Unfortunately all synthetic hormones may cause the following problems:
    •    Insulin resistance
    •    Weight gain - The pill raises SHBG, which affects the thyroid gland. Coupled with insulin resistance, this is the perfect recipe for weight gain. The irony is that some studies have shown the pill to be less effective when BMI is over 27.
    •    Cancer - The pill directly contributes to many cancers. In 2005, the World Health Organization (WHO) declared the pill to be carcinogenic.This is quite sobering in light of how conservative the WHO is.
    •    Compromised gut flora/good bacteria in the gut – Gut flora is highly involved in immunity and general health.
    •    Impaired nutrient absorption
Also, many doctors will prescribe the birth control pill and then not bother treating insulin resistance or any other symptoms, in effect masking them. This is not a good strategy since many women with PCOS find their symptoms worsen after coming off the Pill. The pill simply does not treat the root cause of the problem in any real way. Finally, women with PCOS do not need to contend with all the side effects of the pill on top of the symptoms they already have.
Many doctors recommend the use of the herb vitex (also called agnus castus), natural progesterone cream and Glucophage to induce periods instead.
Hirsutism
Antiandrogens such as Spiroctalene and Flutamide can be used to treat excess hair growth. They are useful for relieving both the symptoms of hirsutism and also of acne. However, they can cause serious birth defects, so most doctors recommend that a very effective contraceptive be used alongside these medicines. There is also a cream called Vaniqa that can be used to treat excess facial hair. This cream slows down the rate of facial hair regrowth. Laser therapy or electrolysis seems to be the best long term solution; however these methods can be painful. Other methods, such as shaving, are quick and generally painless, but only last for short periods of time. Many women also find that Glucophage helps with hirsutism.
Acne
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 do a lot of damage to the gut flora, which is highly involved in immunity,  and topical agents such as benzyl peroxide and salicylic acid. Tretinoin and Roaccutane can be used for severe cases. Both are synthetic forms of vitamin A. Again, they require the use of very strong contraceptives as they can cause severe birth defects.
Obesity
Dieticians/nutritionists educated about PCOS will prescribe a whole food diet that is made up of unrefined carbohydrates, natural fats (limiting trans and polyunsaturated fats), adequate protein and plenty of vegetables. However, many patients will not receive such good advice and will instead be given outdated information from their doctors who will tell them to eat a low calorie, low fat diet. The patient may lose weight, but they will not improve their health and they will most likely feel miserable. In the long run, they are likely to re-gain any lost weight and run the risk of developing an eating disorder. This is because restriction and diets in general are well established risk factors for the development of eating disorders.
Plus, there is growing evidence that it is possible to be healthy at any size. Dr Linda Bacon asserts that staying the same weight (even if it obese) is healthier than going up and down the weighing scales all the time. She asserts that the most important thing is a healthy lifestyle: good diet, exercise and stress reduction. This is knows as the Health at Every Size (HAES) movement. Other advocates of HAES include: Jon Robison, Paul Campos and Matt Stone.
Infertility
This is a vast topic. However, I will delineate the basic treatments offered. Usually women are first offered Clomid to force their body to ovulate. However, this can cause severe PMS and may slightly increase the risk of ovarian cancer. Most doctors will also only prescribe it 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.

Holistic Treatment
Nutrition
PCOS is a chronic illness that is best treated holistically. Therefore, a patient should concentrate on good nutrition first and foremost. There are several excellent books on nutrition out there, including Nourishing Traditions by Sally Fallon, The Diet Cure by Julia Ross and Real Food: What to Eat and Why by Nina Planck. The work of Ray Peat at www.raypeat.com is also very illuminating, as is the work of Matt Stone at www.180degreehealth.com. These authors concentrate on improving health rather than focusing solely on 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, fat and carbohydrate. Quality protein includes: unprocessed meat, fish, eggs and cheeses. Good vegetarian protein sources include: quorn, dairy, soaked beans and the less fermented soy products such as miso or tempeh. It is important to recognise that 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.
Good quality fats include fat from unprocessed meat, dairy and coconut oil. It is imperative that hydrogenated fats and polyunsaturated be avoided since they are inflammatory and carcinogenic. Finally, the right amount of carbohydrates according to activity level, health, insulin status and weight should be consumed in the form of starchy vegetables, soaked grains and fruit.
Refined carbohydrates, white flour, sugar and caffeine should be greatly reduced, and if possible, eliminated from the diet. Women with PCOS should also try to buy organic as much as possible.

Exercise
There is abundant evidence that exercise improves the body's use of insulin. Those with PCOS benefit from both resistance and cardiovascular exercise. Resistance exercise (weight training, swimming, yoga, pilates) builds muscle and thus increases the body's insulin sensitivity. Cardiovascular exercise has many benefits, but must be done in moderation. According to Schwartzbein, “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: Many people have had great success using herbs, but have found only the tincture forms to be effective. Tablets are synthesized in a different way and do not work at all for some people. Anecdotal reports seem to suggest that tinctures are more powerful.
Agnus castus/vitex/chasteberry
This seems to be the herb most commonly used by women with PCOS. Vitex has a direct effect on the pituitary gland, which is 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  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, hirsutism 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".  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 estrogenic effect. It is widely used in menopausal formulas, but is valuable for treating amenorrhea, irregular menstruation, hirsutism 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 oil
This is a very popular supplement taken by many women for PMS, fibrocystic breast disease and skin problems. It can also help with irregular cycles. It is rich in G.L.A and linolenic acid, which are essential fatty acids that the body requires to regulate hormones. Evening Primrose oil may also help with heart disease, cholesterol and blood pressure. It is however a polyunsaturated fatty acid, and many people want to avoid these oils.
Progesterone cream
This cream has been widely popularized 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 or prescribed as a gel by your doctor.
Supplements
Many women with PCOS find supplements very helpful in relieving various symptoms. Recommended supplements for PCOS include: the B complex, a good quality multivitamin with chelated minerals and GTF chromium.

Cod liver oil
According to Jordan Rubin of The Great Physician’s Rx, cod liver oil started out as a medicinal remedy for communities in Iceland, Scotland and Norway who used it to prevent infections during winter. Since then we have discovered that cod liver oil has many other amazing properties. It helps to protect the heart, improves arthritis symptoms, lowers inflammation levels and helps to strengthen teeth and thus avoid cavities, amongst a host of other benefits. Most importantly for women with POCS, it is a natural source of vitamin A and thus is an alternative to Tretinoin and Roaccutane. Many people have found success by changing their diet and taking cod liver oil.
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 than just masking the disorder. Finally, more nutritionists are becoming aware of the damage refined carbohydrates, sugar and hydrogenated fats can 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 www.soulcysters.com and 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 2013 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 and moderated two other PCOS Web sites also. Since then, her PCOS has remained so controlled that doctors consider her practically cured. She currently works as a freelance writer, editor and ghostwriter. She can be contacted at www.lynndunning.com or at http://ie.linkedin.com/pub/lynn-dunning/40/325/426.

Read another article on PCOS, by Dr. Nelson Soucasaux



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