By Dee Atkinson FNIMH
Over the last few years I have been seeing more women presenting in clinic with hormonal problems. In some cases the problems are unmasked when they stop using chemical contraception because they are trying to conceive. In other cases, they have been reading around the subject and have realised that their symptoms could be due to Polycystic Ovary Syndrome (PCOS).
It has been estimated that PCOS affects about 7% of women, but this seems to me to be a conservative estimate. I see many women who have some of the symptoms but have yet to have a definitive diagnosis, and other women who I feel are heading towards developing full blown PCOS.
What is PCOS?
PCOS is a complex endocrine and metabolic disorder which causes abnormal ovarian function (it is the most common cause of failure to ovulate). It is not, as often assumed, a syndrome caused by a disorder of the ovaries. Understanding this is key to developing a treatment and management plan for the patient. Endocrine and metabolic disorders need to be approached with a whole lifestyle and dietary plan, as well as with herbal medicine.
Symptoms of PCOS
Often the main presenting symptom is lack of periods or very irregular periods with long gaps between them. Some women have acne, especially around the jaw line, and some find excess hair growth on their chin, upper lip, forearms and occasionally on the chest. Male pattern hair loss around the forehead and top of the head is a common symptom too. The picture can be muddled by previous use of the pill or other chemical contraceptive devices such as the contraceptive implant. If the period symptoms are masked by this, the patient’s GP may have just prescribed antibiotics for the acne: often the diagnosis has been missed as the individual symptoms are treated without looking at the whole picture.
One of the key diagnostic features that I look for is an excess of belly fat, especially if the waist to hip ratio is such that the waist is larger than the hips. Again, use of chemical contraception can lead to weight increase, making it more difficult to spot the underlying trend.
I often also find symptoms of mild insulin resistance with patients saying they feel dizzy if they eat too much sugar or if they don’t eat regularly. Again, this can be masked by poor diet choices. In some cases the symptoms can be mild and masked with women only discovering them when they have fertility issues or pain from ovarian cysts. A major cause of fertility issues is due to PCOS.
Diagnosis of PCOS
Clinical diagnosis is usually made via a series of blood tests and usually an ovarian scan. As some women have few symptoms other than irregular periods, it is always important to get blood tests done. I have seen women who have been undiagnosed for years and the problem is only picked up when they try to conceive.
Useful blood tests include LH (Luteinising hormone, may be high), FSH (follicle stimulating hormone, may be normal or low), the LH/FSH ratio (if 2:1 or 3:1 if may indicate PCOS), Prolactin, Testosterone (usually elevated), Oestrogen, Sex hormone binding globulin, Androstenedione, Lipid profile, Glucose, HbA1c, Insulin and Thyroid stimulating hormone.
Management of PCOS
Many patients are offered the combined contraceptive pill: this will reduce androgens, regulate menstruation and reduce the risk of endometrial hyperplasia. Both the pill and anti androgen drugs (that are sometimes prescribed) mean the patient cannot conceive whilst using them and the symptoms tend to be masked rather than trying to manage the endocrine and metabolic disorder that caused PCOS.
There has been some interesting work around using insulin sensitising drugs, such as Metformin, and this may help some patients. Patients trying to conceive are often offered treatment with Clomid to improve fertility. Herbal Medicine and Dietary Management of PCOS.
An Integrated Approach:
In clinic, one of the more complex issues in helping patients manage PCOS is around the area of diet. Patients can have years of making poor eating choices, subsequently struggling with weight issues due to developing insulin resistance. Insulin resistance can lead to unusual symptoms and present in clinic as ‘acanthosis nigricans’ (darkened skin patches on the back of the neck, elbows, knees, knuckles or armpits). Other symptoms of insulin resistance can include high blood pressure, cholesterol issues, or simply weight gain around the middle and dizzy spells if their blood sugar drops too far.
In my clinic I encourage patients to move onto a low GI diet with a good choice of complex carbs and proteins. If the overall intake of carbs is reduced, this will help to increase the sensitivity of the insulin receptors and promote weight loss. Helping patients with diet dairies, planning health snacks and looking at ways to increase exercise will all help with weight loss too. There is some evidence to show that reducing the waist to hip ratio will reduce symptoms of PCOS. Often understanding why this can make a difference helps the patient to make the changes.
I also encourage patients to switch to organic dairy and, if possible, to cut dairy right down or out of their diet. I feel the many hormones and xenoestrogens in our modern western diet have an impact on young women’s hormones, and the dairy industry is a major source.
To help manage insulin resistance, I use a combination of herbs including Cinnamon, Goats rue (metformin was developed from this herb), fenugreek and Siberian ginseng. Magnesium deficiency can predispose to insulin resistance, so supplementation with 400mg of magnesium citrate is advised. Chromium (200mg) will also help with managing insulin resistance and sugar cravings.
My herbal dispensary contains many possible options for supporting patients with PCOS. Androgen production may be lowered with herbs such as hops, black cohosh, liquorice and peony. Other herbs, such as shatrivarti, gotu cola, zizyphus and tribulus, are steroidal saponins and can be used at the beginning of a month, helping to regulate the cycle. Herbs such as spearmint and saw palmeto can also be used to reduce free testosterone and reduce symptoms of hyperandrogenism. Traditional ‘blood purifiers’ like sarsaparilla and burdock can help clear up acne issue, I often prescribe these and give advice of skin care routines to try and reduce acne spread. Excess hair growth is best removed professionally to avoid scarring. This will rarely completely stop hair growth on its own, but when done at the same time as using herbs to regulate the PCOS, can give lasting results.
Managing PCOS is complex and there no ‘one remedy fits all’ solution here. Herbal medicine can be successful when the patient and the practitioner work together over a period of months to tackle all of the issues involved. I often feel that if you can catch it early and start treatment as soon as the problems are spotted, you can resolve them faster. I have, many times over the years, managed to correct the early symptoms of PCOS in young women and with them then having a problem free time for years before needing any intervention again.
Further information on PCOS
Verity is a UK charity for women whose lives are affected by PCOS. It is a self-help group for women offering support and providing up to date medical information.
To make an appointment with Dee Atkinson or any other member of our herbal team, please call reception on 0131 225 5542.