Polycystic Ovarian Syndrome (PCOS)

Overview

What is PCOS?

PCOS is a multi-organ disease which results in small cysts on the outer layer of the ovaries with a concurrent hormonal imbalance.   Hormones help regulate the normal development of eggs in the ovaries during each menstrual cycle.

Normal vs. PCOS ovaries during the monthly cycle

Normally.   Each month the ovaries start to ripen a number of follicles, which are actually cysts, tissue sacs filled with fluid and hormones (mostly estrogen.) One or two of these follicles grow stronger than the others and produce and mature an egg. When ovulation is triggered by a surge in luteinizing hormone (LH), the egg in the dominant follicle is released into the fallopian tube en route to the uterus, where either it is fertilized within 24 hours, or it regresses. The now empty egg sac becomes a corpus luteum producing large amounts of progesterone (and smaller amounts of estradiol) to support the pregnancy. If implantation in the uterus does not occur within 2 weeks the corpus luteum usually regresses (via a process called luteolysis) and the uterine lining is shed, seen as menstrual bleeding.

With PCOS.  Alterations in hormonal pathways cause the ovaries to form a number of follicles on the outer layer (cortex) of the ovary. Follicles (egg-containing sacs within the ovaries) normally release one or more eggs during each menstrual cycle - called ovulation. In PCOS, the eggs in the follicles do not mature and are not released from the ovaries. Instead, they can form very small cysts inside the ovary. The ovarian cortex thickens and the egg has difficulty breaking through. No single follicle becomes dominant and ovulation can't occur.

Unlike larger ovarian cysts (follicles > ~ 2 cms), PCOS cysts do not cause pain and rupture, but because a woman with PCOS doesn't ovulate, hormonal cycles are disturbed causing high levels of estrogens and androgens (E.g.testosterone and DHEA), yielding symptoms of estrogen and androgen excess.

Hormonal imbalance with PCOS

 In particular, too many androgens (male hormones) are produced. It is not well understood why or how the changes in the hormone levels occur, but these changes can result in:

• Infrequent or no ovulation - making it more difficult to conceive
• Interference with egg release - androgens play a role in blocking egg release
• Higher than normal risk of miscarriage - associated with poorer egg quality; 

Higher insulin levels / insulin resistance - in a majority of women with PCOS

Minimum criteria for PCOS diagnosis

NIH concensus, from 1990 conference:

• Menstrual irregularity - due to infrequent or no ovulation (i.e. oligo- or anovulation); menstruation may be more or less frequent, and may range from very light to very heavy
• Evidence of hyperandrogenism - E.g. hirsutism, acne, male pattern balding, high serum androgen; PCOS is the cause of > 70% of cases of androgen excess/secondary hirsutism
• Exclusion of other disorders - such as congenital adrenal hyperplasia (CAH), androgen-secreting tumors, or hyperprolactinemia

Symptoms / Characteristics of PCOS

Hyperandrogenism

Including:

• Development of male sex characteristics (virilism):   Decreased breast size, deepening voice, enlarged clitoris (rare), and hirsutism (increased hair on any of chest, abdomen, face, stomach, back, thumbs, toes, around the nipples)
• Male-pattern baldness.    A thinning of hair on head
• Skin changes.   Acne and dark/thick skin markings/creases around the armpits, groin, neck, and breasts due to insulin sensitivity; skin tags or tiny excess flaps of skin in armpits or neck area

Changes in secretion of pituitary gonadotrophins: growth hormone(GH) and ACTH.

Inefficient cortisol production results in rising levels of ACTH (stress-responsive hormone for stimulating adrenal cortisol production) which in turn induces overgrowth (hyperplasia) and over-activity of the steroid-producing cells of the adrenal cortex.

Insulin resistance / Weight gain (usually around the waist) / Type 2 diabetes.

It is possible that hyperinsulinemia can actually cause an increase in androgen and probably ovarian hormone production.

• The majority of patients with PCOS have insulin-resistance (IR).    Associated with an increased risk of metabolic syndrome, type 2 diabetes and obesity; IR leads to high blood insulin levels and according to Jerilyn Prior, M.D., insulin stimulates androgen receptors on the outside of the ovary, causing the typical symptoms of hyperandrogenism (see above);
• insulin resistance has been linked to recurrent pregnancy loss.   High insulin levels stimulate production of LH and testosterone and excessive levels of insulin, LH and testosterone are associated with poorer egg quality, thus increasing the risk of miscarriage.
• Androgens play a role in blocking the release of the egg from the follicle and producing cysts.

insulin Resistance (IR)

An unhealthy diet is a contributing factor of PCOS

Young women with PCOS tend to eat too much sugar and refined carbohydrates giving rise to IR with inherent unhealthy insulin levels.

Characterized by an increased inflammatory state

With increased secretion of interleukins, chemokines, and adipokines.

Increased bone mineral density

Despite decreased vitamin D levels.

Possible iodine deficiency

Causes impaired thyroid function, suggested as a factor in PCOS development.  The ovary has the highest concentration of iodine, second only to the thyroid.Iodine also has a critical role in insulin function, which may explain the insulin resistance often seen in PCOS. An iodine loading test determines whether you are deficient by testing amount of iodine excreted in urine over 24 hours. If you don't excrete it, your body needed it and you are therefore iodine deficient.

How to treat polycystic ovarian syndrome (PCOS)

There are two main goals in dealing with PCOS and preventing related miscarriage:

(1) Balance hormones

Normalize hormones to improve ovulation.    Particularly balance sex steroid hormones (i.e. estrogens, androgens, progesterone; many women with PCOS have high levels of Testosterone and low levels of progesterone)

Improve thyroid activity.   Improving thyroid function can eliminate ovarian cysts - by lowering estrogen levels and causing the ovaries to produce more progesterone. The best ways to accomplish this is via:

• Thyroid hormone supplementation - using dessicated porcine thyroid gland containing a natural mix of thyroid hormones, not ineffective synthetic forms - see Thyroid Replacement Hormones)
• Iodine supplementation (this author's preferred choice) - Dr. Jorge D. Flechas, a renowned author and expert in iodine supplementation, writes that iodine deficiency in the ovaries may cause the ovaries to develop cysts, nodules and scar tissue and has patients who have successfully eliminated ovarian cysts by taking a daily 50mg dose of a specific combination of iodine and iodide (E.g. Lugol's solution or Iodoral®) for 2-3 months. Orthoiodosupplementation in a Primary Care Practice

Iodine -The universal medicine

Reduce estrogen levels.  Supplement DIM and/or use other methods to reduce body's estrogen levels.    DIM aids in the breakdown of non-beneficial estrogen metabolites. Estrogen is a major culprit in many fertility issues faced by women today including PCOS.

DIM - Estrogen Blocker with anti-cancer benefits

How to reduce estrogen levels

Supplement progesterone.  Directly supplement a physiological dose of progesterone.    Dr. John Lee (author of "What your doctor may not tell you about Premenopause", and a pioneer of progesterone supplementation for hormonal imbalance) said that natural progesterone administered on specific days of the menstrual month for two to three cycles, will almost routinely cause disappearance of ovarian cysts,  by suppressing normal FSH (follicle-stimulating hormone), LH (luteinizing hormone), and estrogen production and giving the ovary time to heal. For details on progesterone therapy, which for a women is best delivered via the vaginal route using suppositories, see:

Estrogen dominance treatment

Other helpful hormone balancing supplements

• Drink peppermint tea twice daily.   To reduce your Testosterone levels (1 tsp. steeped in hot water for 5-10 minutes). This has been found to be more effective than medication.
• Supplement folic acid.   Taking extra folic acid as much as a year before pregnancy has been shown to reduce miscarriage.
• N-acetyl cysteine (NAC).    Reported to ease PCOS symtoms.

(2) Normalize blood sugar (glucose) levels

LOWER intake of sugar / refined carbs / fructose (including too much fruit or fruit juice)

Top 8 reasons to adopt a low-carb diet for polycystic ovary syndrome

Metformin (Glucophage).    Reported to reduce the rate of miscarriage in women with PCOS by controlling blood sugar levels.