A NEW PROGRAM FOR HEALING PCOS!
This is the third post in a series about Polycystic Ovarian Syndrome (PCOS). Start with the first post. In the second post I write about PCOS current diagnostic criteria. Here I cover treatment for this condition.
Since my specialty is Functional Medicine, I will briefly write about conventional treatment, and then focus on a Functional approach.
Conventional treatment for PCOS
Allopathic medicine relies on pharmaceuticals to mitigate symptoms, which typically fit into four categories: menstruation-related disorders, androgen-related symptoms, insulin resistance, and infertility.
This primarily means irregular menstrual cycles. If you have PCOS, it’s likely you don’t ovulate every month. Women with infrequent cycles often ovulate only eight times a year, or less often. Why is this a problem? When you don’t shed your uterine lining regularly, your risks for endometrial (uterine) cancer increase.
This is treated with combined hormonal contraceptives (CHC). Often doctors use progestin cyclically, or a combination of progestin and estrogen. The goal is to enable you to cycle regularly.
These symptoms are due to high levels of your androgen or “male” hormones – testosterone and DHEA. The most common symptoms are male pattern hair growth such as on your cheeks and chest (hirsutism), hair loss on your scalp (alopecia), and acne.
Conventional treatment to lower androgens includes oral contraceptive pills (OCPs) and androgen-blocking medications. For women who aren’t trying for pregnancy, this combination of medications is typically the go-to in conventional medicine.
It may take at least six months to create a difference in your symptoms. Therefore many women opt for acne medication, or other means of hair removal such as laser.
Insulin resistance phenotype
64% of women with PCOS have insulin resistance. If you fall into this category, losing weight and managing your blood sugar and insulin will help regulate your hormones. Conventional medicine relies on diabetes medications, the most popular being Metformin. These medications are used off-label for PCOS, meaning they aren’t FDA approved. However, Metformin is very commonly used, because it reduces insulin resistance, can cause weight loss, and may help women ovulate. This medication is the go-to for women who are overweight and clearly have insulin resistance.
The downside of Metformin is that it does cause digestive distress for many women. However; others tolerate it with no problem. No pharmaceuticals are free of potential side effects, and they usually don’t correct underlying root causes, they just mitigate symptoms. This is why you often stay on pharmaceuticals indefinitely, because they are not fixing anything.
This is possibly the reason why PCOS has become quite well known. With the plethora of fertility clinics and reproductive endocrinologists, we have discovered that PCOS is responsible for 30% of infertility cases.
The first line pharmaceutical therapy for inducing ovulation is Clomiphene citrate (Clomid), which you can take up to six times. Many doctors combine this with Metformin, which shows mixed results in studies as to whether or not it can promote ovulation. An alternative to Clomid is Letrozole, which helps testosterone convert to estrogen and results in greater chances for ovulation. Currently there is a study taking place that compares the effectiveness of Clomid to Letrozole.
The second line pharmaceutical therapy is called gonadotropin therapy, which increases follicle stimulating hormone (FSH). This must be done very carefully because with PCOS you have a greater sensitivity to FSH, and these medications can hyper-stimulate your production of follicles. Another second line approach is laparoscopic ovarian drilling (LOD). This surgery involves drilling small holes in the surface of your ovaries, and is done as a one-time procedure. So if you have failed first-line therapy, and you aren’t a case for gonadotropins, this is an option.
Lastly, the third line approach is going straight to in-vitro fertilization (IVF). According to this meta-analysis, women with PCOS undergoing IVF have the same pregnancy rates as women who don’t have PCOS.
Functional Medicine approaches to PCOS
Functional Medicine is a great approach to polycystic ovarian syndrome, because the syndrome in itself is poorly understood, and women present with different types and symptoms. It’s “syndromes” such as this that often respond well to a Functional approach.
What is different about a Functional Medicine approach? Instead of trying to control symptoms with pharmaceuticals, we perform a differential diagnosis for each woman. This means we identify your type of PCOS.
Then we assess and treat underlying causes and imbalances that contribute to the expression of your PCOS. Yes, there may be genetics in play. However; even with genetics there are always things we can do to influence the course of this syndrome.
Lastly, patient education is essential. Knowledge of the risk factors that I detailed in the second post is important! Most PCOS women who come to see me don’t know they have it. Often their concerns are getting pregnant, losing weight, stopping hair loss, or getting rid of acne. It’s my job to look at the bigger picture of your future health risks, and educate you about how to reduce these risks.
The insulin resistant type is fairly straightforward. First, lose weight.
Research shows that a loss of just 5–10% of body weight is enough to restore reproductive function in 55–100% within 6 months of weight reduction.
Just as obesity expresses and exaggerates the signs and symptoms of insulin resistance, then loss of weight can reverse this process by improving ovarian function and the associated hormonal abnormalities. Loss of weight induces a reduction of insulin and androgen concentrations.
I realize that weight loss is easier said than done. Since I do not prescribe pharmaceuticals, I get to help you lose weight without Metformin, which is entirely possible for most women.
The dietary approach is to eat carbohydrates in the form of whole foods instead of refined/processed starches and sugars. This alone will make a big difference. Then we explore how much carbohydrate you can handle in a meal without blood sugar going too high. I’ll have my patients get a glucometer from the drugstore and test their blood sugar before and after a meal, to figure out what foods keep their blood sugar at a decent level. If blood sugar goes too high, insulin follows. When this is chronic, your cells become resistant to insulin. This is reversible if it’s not too advanced.
Besides diet I’ll also use supplements that increase insulin sensitivity and help regulate blood sugar. The approach to reversing insulin resistance in PCOS is essentially the same as “regular” insulin resistance, metabolic syndrome, or prediabetes.
The menstruation-related and infertility types go together
Essentially these have the same etiology; meaning they both involve a lack of regular ovulation. If there is no insulin resistance, there is still a likelihood of high androgens in this type. There’s also a likelihood of imbalanced female sex hormones. Usually progesterone is low, and estrogen can be high, normal or low.
With this type it’s still important to work with a diet that regulates insulin, because even with no evidence of insulin resistance, this dietary approach is shown to reduce androgens. Often we will add herbs and supplements to help reduce androgens. In addition, we may choose vitex or small amounts of bioidentical progesterone to boost progesterone production and restore your HPO (hypothalamus-pituatary-ovarian) axis. Another way to say this is restoring the signaling between your brain and your ovaries so that you produce more progesterone.
Our goal is to promote regular menstrual cycles and ovulation, with natural methods. When we identify precisely which sex hormones are out of balance, we can target natural treatment with precision.
With this type we also want to pay attention to how you metabolize your hormones. Are you metabolizing and getting rid of excess testosterone, DHEA, and estrogen efficiently? By assessing your hormone metabolites and detoxification abilities, we can continue to target your individual treatment.
The Atypical PCOS type
This type is the one that is most likely to fall through the cracks with a conventional approach. If you fall into this category, you may have no evidence of insulin resistance, and your androgen levels may be fine. You may even have regular menstrual cycles. Yet upon closer look, we may find that you aren’t ovulating with each cycle. Or, you may actually have ovarian cysts. You may not know you have cysts because there’s never been a reason to look for them. You may be thin, healthy, physically fit, and not very hairy.
We need to take a deeper investigation into what is driving your PCOS because it’s not as straightforward. Again, it can be due to genetics. However, even when a condition is due to genetics, there are still interventions we can do to alter the course.
Assess all hormones
Once we’ve ruled out insulin resistance and high androgens, I like to do a deep and thorough assessment of all other hormones – this includes thyroid and thyroid conversion, all sex hormones, and cortisol, an adrenal hormone. Sometimes we will discover a thyroid condition. This could be functional hypothyroid, meaning there’s nothing wrong with your thyroid and you don’t have thyroid autoimmune disease, but your levels of circulating thyroid (T-3) are low. We dig into the reasons for this.
Sometimes progesterone is low, often estrogen is high. Again we dig into the reasons for this. If estrogen is high, this could be due to exposure to estrogens in the environment, so we want to reduce those. These are called xenoestrogens. To some extent we cannot avoid them because they are pervasive in the environment, but there are many ways we can control our exposure. High estrogen can also be due to poor metabolism. In these cases we investigate detoxification ability.
If cortisol, or your brain-adrenal axis is out of balance (HPA, for hypothalamus-pituitary-adrenal), then we need to correct this. HPA disorders respond well to natural approaches. We use a combination of lifestyle and supplements. You cannot just take supplements to correct HPA disorders, you must address lifestyle factors. This includes the way you perceive and manage stress, and your sleep habits.
Acupuncture effective for PCOS
There are countless studies on the effectiveness of acupuncture for PCOS, here are a few:
Acupuncture therapy has a role in PCOS by: increasing of blood flow to the ovaries, reducing ovarian volume and the number of ovarian cysts, controlling hyperglycemia through increasing insulin sensitivity and decreasing blood glucose and insulin levels, reducing cortisol levels and assisting in weight loss.
Several clinical and animal experimental studies indicate that acupuncture is beneficial for ovulatory dysfunction in PCOS.
This meta-analysis showed that the clinical efficacy of simple acupuncture was the same as that of western medicine, and the efficacy of acupuncture combined with Chinese herbal medicine interventions was obviously higher than that of western medicine. In addition, simple acupuncture intervention and acupuncture combined with Chinese herbal medicines or with moxibustion treatment have advantages in reducing serum luteinizing hormone/follicle-stimulating hormone (LH/FSH), insulin resistance (IR), testosterone (T), and body mass index (BMI).
Acupuncture has been demonstrated to improve menstrual frequency and to decrease circulating testosterone in women with polycystic ovary syndrome (PCOS).
We conclude that repeated acupuncture treatments resulted in higher ovulation frequency in lean/overweight women with PCOS.
Was PCOS an evolutionary advantage?
This fascinating paper explores the history of PCOS. The authors conclude that PCOS is an ancient disorder, arising from ancestral gene variants selected during the Paleolithic Period and maintained over the past 10,000 years following the onset of Neolithic culture.
But why would a genetic “disorder” that includes subfertility continue over millennia? For one, men who are genetic carriers of PCOS (written about in the last post) may have high androgens and insulin resistance, but they don’t have fertility issues, so their PCOS genes can be easily passed.
Women with PCOS and high androgens are historically stronger and more robust, which would have been advantageous for survival during both Paleolithic and Neolithic cultures, including during childbirth. Women with PCOS are not infertile, they are subfertile. Having children less often during the Paleolithic era would have been advantageous, because spacing children during this era supported the nomadic hunter gatherer lifestyle.
It is likely that during the Paleolithic era, environmental stressors favored the survival of those with the greatest capacity for energy storage necessary to endure prolonged episodes of food scarcity, the so-called “thrifty genotype.” Such a thrifty genotype may have enhanced survival during times of food deprivation, with reduced post-meal energy expenditure from insulin resistance as an additional evolutionary advantage.
A NEW PROGRAM FOR HEALING PCOS!