Polycystic Ovarian Disease

This one is complex, more so than you may realize, but it is also much more simple than many in healthcare make it out to be. As many as 17.8 percent of women are impacted by #PCOS (Arentz et al., 2014). It is the most common endocrine problem in childbearing women and really has significant consequence, so as clinicians, we really do need to lean into this one and help women understand their diagnosis and empower them through education.

Polycystic ovarian syndrome is both a metabolic issue, as well as endocrine. Hormone imbalance leads to higher than normal levels of #testosterone which can lead to weight gain, hair loss, and even hair growing in odd places like your chin, upper lip, even your breasts and lower belly. Cystic acne is also common and combined with the previous symptoms, can really wreck one's self-esteem. Depression and sleep apnea leave many exhausted and miserable, even disrupting one's ability to really get through their day. High blood pressure, obesity, and even cardiovascular disease and insulin resistance are additional risks.

Use to we had to take a panel of tests to confirm the diagnosis, but today, this is fairly easily diagnosed on clinical exam. Infrequent periods, more than every 35 days, and symptoms of excess androgens such as acne, hair loss, or hair in unwanted places is really sufficient. Being overweight exacerbates all aspects of PCOS due to underlying metabolic disturbances. Many do have polycystic ovaries, which can be observed via ultrasound, but the absence of these does not rule out diagnosis so it is not often obtained. Findings of cysts on ultrasound does also not in itself diagnose PCOS. Infertility is common, so is dark, velvety-textured skin around the neck and in the armpits and groin, but again, not diagnostic in itself. Skin tags are also common because they also occur with insulin resistance, which is also common to PCOS.

The PCOS Imbalance

Individuals with PCOS have brains that continue to instruct the ovaries to mature follicles but because of the high androgens, these follicles aren't released. Ovulation commonly doesn't occur. In fact, cycles don't oven occur, so menses may be very irregular. When they do occur, menses are often heavier and painful because they are so infrequent. This build up of endometrium between cycles these women at risk for endometrial cancer and heavier periods put women at risk for anemia. Of course, this makes infertility a common challenge among those with PCOS.

Insulin also causes the body to store weight, adding to the poor self-esteem, but also the potential for blood pressure and heart disease. Sadly though, #obesity is one of the more poorly addressed issues in healthcare, with lots of judgement, bias, and even fat shaming. So often weight gain is thought to be about little more than too many calories in and too few calories out, so a matter of poor will-power which invites judgement. PCOS then goes undiagnosed in more overweight women, but is also missed entirely in women who aren't overweight because this is thought of as a "fat woman's" disease.

More recently binge eating has been associated with PCOS. Women blame themselves for "weakness" and poor willpower, when it is the condition itself causing this symptom. Subclinical hypothyroidism with elevated thyroid antibodies should be evaluated as well, and keep in mind that other autoimmune diseases are also common with PCOS. Cholesterol may be increased, even fatty liver disease, and we can't overlook mental health consequence.

Signs and symptoms are mediated by hormonal disorder including elevated androgens and fasting insulin, and abnormal relative ratio of the gonadotropins luteinising hormone (LH) and follicule stimulating hormone (FSH) (Arentz et al., 2014). Simply giving women a pharmaceutical bandaid doesn't fix the underlying issue, and will ultimately lead to further consequence. Most often women are offered the oral contraceptive pill and ovulation induction with clomiphene citrate (clomiphene) depending on fertility needs, but often women with PCOS aren't good candidates for this therapy. In fact, conventional pharmaceutical management is limited by the prevalence of contraindications in women with PCOS or is entirely non-effective in some circumstances, has side effects, or women simply prefer alternatives to pharmaceutical management.

Management for hyperandrogenism includes anti-androgens and hypoglycemic pharmaceuticals such as metformin (Arentz et al., 2014). Many women suffer nausea, vomiting, and stomach upset with these medications. Herbal medicines have more commonly be integrated into care plans by functional and integrative practitioners, as well as by herbalists, midwives, and naturopathic providers. Consider though, that the implementation of herbs can also take a band-aide approach and our efforts really need to be at correcting the underlying issue, so let's peek here first.

Stress & PCOS

When we are under chronic stress, we are much more likely to suffer blood sugar problems and insulin resistance - a key factor in PCOS for at least 70 percent of women with this condition. When we are stressed we eat more sugar and carbohydrates because we want the dopamine and energy; it also helps support production of cortisol. Our #insulin elevates to manage all this sugar and this triggers our ovaries to produce more testosterone.

When we're under #stress, our adrenals increase their production of DHEA and androstenedione production because these hormones help to buffer the brain from the impact of cortisol, our stress hormone. When elevated they also contribute to PCOS and its symptoms. We aren't quite sure why, but women with PCOS are especially sensitive to the effects of cortisol, so these reactions are all a bit exaggerated.

As if this isn't enough, other hormones are also a bit awry which creates additional sequelae. Leptin for example controls our #appetite and satiety, but can be higher in women with PCOS, so these women are more susceptible to cravings and binge eating and having a tougher time losing weight. Getting out of chronic stress to reset the brain-ovary and adrenal-ovary connections are important secrets to halting PCOS. We have programs for our members that address just this!

Vitex is the Women's Health Botanical

Generations of herbalists and cultures all over the world have recognized vitex or chasteberry as the women's botanical because it addresses so many different issues within women's health. Vitex agnus-castus has been found to lower prolactin, improve menstrual regularity and treat infertility, so is especially appropriate for women with polycystic ovarian syndrome (Arentz et al., 2014). Interestingly, studies are recognizing that vitex has a variety of compounds which bind to dopamine type 2 (DA-2) receptors in the brain, and it reduces cyclic adenosine mono phosphate or cAMP, as well as lowers prolactin secretion. In fact, #vitex has demonstrated to be as effective as lowering prolactin as the pharmaceutical, Parlodel 5mg daily.

Black Cohosh Potentially Lowers LH

Cimicifuga racemosa, black cohosh, was found to lower LH in two laboratory studies, both conducted on rats (Arentz et al., 2014). The mechanism occurred through competitive inhibition of estrogen following the selective binding of estrogen receptors (ERa) on the hypothalamus and pituitary. Three random control trials support this finding, and the positive fertility effects for black cohosh in women with PCOS when used independently of or in conjunction with clomiphene. Two studies have found when black cohosh is offered at 20mg a day, alongside clomiphene 150mg, pregnancy rates more than double those who take clomiphene alone.

Tribulus Terrestris Improves Ovulation

Two laboratory based random control trials have found tribulus terrestris, or gokshur, improves ovulation in rats with polycystic ovaries, with just two doses. Laboratory findings supported these findings with elevated FSH following treatment (Arentz et al., 2014). Another prospective, observational study observed a significant increase in mean serum FSH concentration in just five days of treatment with 750mg per day of tribulus terrestris. Pre-treatment FSH levels returned following cessation of treatment. When tribulus terrestris was compared to pharmaceuticals for ovulation, epimestrol had the highest incidence of ovulation at 74%, then tribulus terrestris at 60%, then clomiphene at 47%, and finally, cyclofenil at 24%.

Licorice Root May Lower Androgen Levels

Three clinical trials have found Glycyrrhiza spp effective in lowering androgen levels (Arentz et al., 2014). Free and total testosterone were both significantly reduced, and oestradiol was increased. These hormonal effects were thought to occur primarily in the ovary via enhanced aromatisation of testosterone to 17-beta oestradiol. There were no changes to FSH or LH in androgen sterilized or oophrectomized rats.

Another study evaluating glycyrrhiza uralensis (Chinese licorice) found significantly increased ovulation rates by the number of corpus luteum in polycystic ovaries compared with controls (Arentz et al., 2014). The theory here is that there was competition for the estrogen receptor sites, limiting the production of nerve growth factor (NGF), creating neurotrophic effects and inhibition of sympathetic neurological involvement in the pathogenesis of polycystic ovaries.

Two additional studies evaluating licorice found it reduced testosterone in healthy women over just two menstrual cycles when offered 7 grams per day. And yet another study found reduced testosterone with only 3.5 grams per day when added to the anti-androgen pharmaceutical treatment, Spirinolactone 100mg, daily, over two menstrual cycles. Interestingly, Spirinolactone has a side effect of flaring androgens during the initial phase of treatment, but this was not found when licorice was added to treatment.

Peony & Licorice Together Reduce Testosterone

One laboratory study and two clinical investigations have found that these two botanicals, together, reduce free and total testosterone in women with PCOS and in women with hyperandrogenism, by almost half (Takeuchi et al., 1989; Yaginuma et al, 1989; & Takahashi & kitao, 1994). Both clinical trials utilized equal parts of glycyrrhiz uralensis and paeonia lactiflora, 75 grams per day for 24 weeks and 5-10 grams per day for 2-8 weeks, respectfully. These were small studies so still lots to explore here.

Cinnamon Improves Various Risk Factors in Women with PCOS

Cinnamon bark is used in traditional Persian medicine to regulate menstrual cycles in those with PCOS, and it has been shown to lower blood glucose and reduce the homeostatic model assessment of insulin resistance (HOMA-IR) index, a measure of insulin sensitivity, in those with diabetes. Two double-blind, randomized, controlled clinical trials evaluated the effects of cinnamon supplementation on metabolic factors such as serum insulin, HOMA-IR index, lipid profiles, and levels of adiponenctin in women with PCOS.

Borzoei et al (2018) found 500mg of cinnamon bark powder three times a day, for eight weeks, compared to placebo, offered significant decreases in weight and BMI, while no significant changes were seen in the control group. In the cinnamon group, intakes of energy and total fat decreased and intake of protein increased after eight weeks, compared with baseline values. Significant improvements were seen in serum glucose, insulin, and HOMA-IR index in the cinnamon group after eight weeks, compared with baseline values. Significant improvements from baseline were also seen in all lipid variables were seen in the cinnamon group after eight weeks, but no changes were seen in the control group.

Hajimonfarednejad et al. (2018) studied the effects of cinnamon bark powder on insulin resistance in women with PCOS. The cinnamon group had significantly greater reductions in fasting insulin, HOMA-IR index, and LDL-C levels after 12 weeks. Fasting insulin and HOMA-IR declined substantially over the course of the study in both groups, though significantly more so in the cinnamon group. Body weight, BMI, waist circumference, fasting blood sugars, two-hour post-prandial blood glucose, lipid levels, and serum androgenic hormone levels were also improved in the cinnamon group. Testosterone levels significant decreased in the cinnamon group by the end of the study.

Another study specifically compared cinnamon and the pharmaceutical, Metformin, on hormone concentrations in rats with PCOS, and both groups had significant improvement in testosterone, LH, and insulin resistance (HOMA-IR).

Peony & Cinnamon

Significant reductions in LH has been found in women with PCOS, as well as improved ovulation in those who had not been ovulating previously, when given a peony and cinnamon combination. They were given different doses of the product, Unkei-to, over 48 hours, but the range was 0.3mg/mL to 7.5 grams per day.

Thoughts from an Herbalist

Vitex, black cohosh, and tribulus terrestris initiate endocrine effects in the pituitary as evidenced by lowered prolactin and LH levels, and raised FSH. Tribulus, licorice - alone and in combination with peony, and cinnamon - alone and in combination with peony demonstrates morphological changes in polycystic ovaries and steroidogenesis, including reduced ovarian volume and cysts, lowered androgens, improved insulin sensitivity and increased oestradiol. Not one of these studies mentioned demonstrated adverse effects in any of these botanical medicines. It certainly seems prudent, if not wise, to consider complementing treatment for PCOS with any one of these herbs as appropriate for women.

References

Arentz, S., Abbott, J. A., Smith, C. A., & Bensoussan, A. (2014). Herbal medicine for the management of polycystic ovary syndrome (PCOS) and associated oligo/amenorrhoea and hyperandrogenism; a review of the laboratory evidence for effects with corroborative clinical findings. BMC Complement Altern Med, 14, 511. doi: 10.1186/1472-6882-14-511

Borzoei, A., Rafraf, M., & Asghari-Jafarabadi, M. (2018). Cinnamon bark supplementation results in improvements in insulin and lipid profiles. Asia Pac J Clin Nutr, 27(3), 556-563. doi: 10.6133/apjcn.062017.02

Hajimonfarednejad, M., Nimrouzi, M., Heydari, M., Zarshenas, M. M., Raee, M. J., & Jahromi. B. N. (2018). Insulin resistance improvement by cinnamon powder in polycystic in polycystic ovary syndrome: A randomized double-blind placebo controlled clinical trial. Phytother Res, 32(2), 276-283. doi: 10.1002/ptr.5970

Takeuchi, T., Nishii, O., Okamura, T., & Yaginuma, T. (1989). Effect of traditional herbal medicine, shakuyaku-kanzo-to on total and free serum testosterone levels. Am J Chin Med, 17(1-2), 35-44.

Takahashi, K., & Kitao, M. (1994). Effect of TJ-68 (shakuyaku-kanzo-to) on polycystic ovarian disease. Int J Fertil Menopausal Stud, 39(2), 69.

Yaginuma, T. I., yasui, R., Arai, H., & Kawabata, T. (1982). Effect of traditional herbal medicine on serum testosterone levels and its induction of regular ovulation in hyperandrogenic and oligomenorrheic women. Nippon Sanka Fujinka Gakkai Zasshi, 34(7), 939.