The naturopathic approach to PCOS
The tendency to PCOS is genetic but is exacerbated by lifestyle and nutrition factors. The naturopaths approach is to:
* Treat insulin resistance through dietary and lifestyle changes. Insulin resistance is made worse by obesity, poor diet and stress (9), lack of exercise and smoking. Increased consumption of saturated and total fat in the diet and a decreased intake of fibre are associated with insulin resistance(14).
Weight loss is essential (if overweight) and the aim is to reduce body fat while sparing muscle tissue. The type of diet that can help achieve this outcome is a high protein and low carbohydrate diet where refined carbohydrates [products containing white flour and sugar] are avoided and low glycaemic index foods consumed. Increase your daily exercise from 30 to 60 minutes per day and include both aerobic and resistance training. Exercise improves insulin sensitivity in skeletal muscles and fat tissue, reducing elevated fasting blood sugar and insulin levels (14).
In order to control insulin resistance weight loss is essential; normalising your body mass index (BMI) to less than 25 and a waist to hip ratio of less than one will go along way to correcting PCOS. For more information on insulin resistance and calculation of your BMI see the Nourish article titled “Glycaemic index – Its impact on pregnancy, hormonal balance …”
Dietary mineral deficiencies might also promote insulin resistance. Calcium, magnesium, potassium, chromium, vanadium and zinc appear to be the most important (14).
Herbal medicines used to help reduce insulin resistance include: Gymnema sylvestre, Galega officinalis (Goat’s rue), Trigonella foenum-graecum (Fenugreek), bitter herbs and Panax ginseng (Korean ginseng), Eleutherococcus senticosus (Siberian ginseng) and Smilax ornata (Sarsaparilla)(10).
* Regulate hormone levels in order to stimulate ovulation and regular menstrual periods. This not only increases the likelihood of conception where desired, it is necessary to protect the uterine lining against adverse cellular changes (endometrial hyperplasia) that could predispose to endometrial cancer.
In order to support the reproductive system, initiate ovulation and normalise follicle development and improve fertility, reproductive tonic herbs are prescribed. These may include: Paeonia lactiflora, Tribulus terrestris, Dioscorea villosa (Wild yam), Asparagus racemosus (Shatavari), Aletris farinosa (True unicorn root), Angelica sinensis (Dong quai), Rehmannia glutinosa, Cimicifuga racemosa (Black cohosh) and Chamaelirium luteum (False unicorn root - although this is endangered so Shatavari is preferred).
Black cohosh, Humulus lupulus (Hops), Paeonia and Liquorice are also used to help normalise and reduce LH levels.
* When acne and male-pattern hair growth or baldness is present herbal medicine is focused on correcting the imbalance between male and female hormones and frequently a combination of Glycyrrhiza glabra (liquorice) and Paeonia is used, in combination with soy milk. Liquorice cannot be used in cases of high blood pressure as it can cause sodium retention and worsen this condition.
A combination of Paeonia and Liquorice has been used in Chinese and Japanese traditional medicine and have been shown to significantly decrease testosterone in women with defined PCOS and in those described as infertile and without menstrual periods or with erratic menses. Paeonia and liquorice has also been used to reduce elevated prolactin levels(11).
Peppermint or spearmint tea has previously been shown to have anti-androgenic effects in rats, and in a small study of 21 women with excessive hair growth (12 of who had PCOS), drinking 2 cups of spearmint tea daily in the first phase of the menstrual cycle (day 1 to day 14 , starting with first day of period) resulted in a decrease in free testosterone and an increase in FSH, LH and oestradiol levels(13). These beneficial testosterone reducing and active oestradiol increasing effects would be important during the first half of the menstrual cycle and spearmint or peppermint tea could be taken 3 times daily, steeped for 10 minutes covered with a saucer to prevent loss of essential oils.
* Women with PCOS have insulin resistance and are at higher risk of developing cardiovascular disease, hypertension, high blood cholesterol, impaired glucose tolerance and non-insulin dependent diabetes (type 2). They also have a higher risk of developing precancerous and cancerous changes of the uterine lining if they don’t menstruate regularly, as well as gestational diabetes during pregnancy(10). Dietary and herbal treatment is aimed at reducing these tendencies.
* Address stress promoting factors. Long term stress adversely effects the endocrine system and worsens insulin insensitivity and affects the ovaries and thyroid gland(9). Elevated insulin (and insulin-like growth factor) stimulates male hormone production from ovaries, adrenals and fat tissue(9). Long term stress causes the adrenal glands to produce high cortisol levels which in turn disrupt pituitary-reproductive hormonal balance and worsens the plight of PCOS(9).
The natural approach to dealing with stress includes: meditation, creative visualisation, neurolinguistic programming (NLP), emotional freedom therapy (EFT), hypnotherapy and cognitive behavioural therapy (CBT) and also use of herbal medicine such as: nervine tonics and nervine relaxants herbs and adaptogens (that are considered to help buffer the body against the adverse effects of stress). Withania somnifera, Turnera diffusa (Damiana), Rehmannia and the ginsengs are such examples. Anxiety is differentiated from depression and treated with different herbs according to the individual presentation.
* Correct imbalance of gut flora/dysbiosis and support liver function. This can be assisted by increasing foods high in dietary fibre, and regular use of a probiotic formula, sauerkraut, lactic fermented vegetable juice and miso soup. To support liver function take the juice of one lemon in hot water first thing in the morning, avoid alcohol, drink dandelion root coffee and regularly eat mescalen salad that contains bitter green leaves.
Liver supportive herbs are usually prescribed and may include: Silybum marianum (Milk thistle), Schisandra chinensis, Curcuma longa (Tumeric), Rosmarinus officinalis (Rosemary) or Bupleurum falcatum(11). Hormone by-products are excreted by the liver in bile and depending on the make up of gut flora, can be reabsorbed from the digestive system, worsening hormonal imbalance. For this reason naturopaths put a lot of emphasis on gut flora and liver function.
* Increase soluble fibre intake; aim for 40 grams daily as part of a whole foods diet. Eat 10+ fruit and vegetables daily, legumes e.g. humus and take 1 tablespoon of ground linseed (10 gram) mixed with unsweetened yoghurt daily.
A diet low in vegetables might contribute to insulin resistance(14). It appears that the amount and range of carotenoid-like pigments in an individual’s blood is related to fasting insulin levels. The higher the carotenoid-like pigment level the lower the fasting insulin levels(14), so make sure you eat plenty of vegetables, salads for lunch and steamed vegetables at dinner-time.
* • Generally use soy milk as opposed to cow’s milk. The phyto-oestrogens, isoflavonoids (present in soy milk) and lignans (present in linseed/flaxseed) stimulate liver production of SHBG which reduces the availability of testosterone to hormone-sensitive tissue(7). The phyto-oestrogens are also capable of slowing down the production of non-ovarian oestrogen (oestrone) produced in fat tissue. Ten grams (1 tablespoon) of ground linseed/flaxseed taken daily has been shown to improve menstrual regularity and ovulation rates amongst normal women. Researchers found that the oestrogen:progesterone ratio improved(12).
Naturopathic treatment and herbal medicines are prescribed based on the individual themselves, their health history, test results and symptom picture and not on the condition specifically, although this is considered important. When prescribing herbal medicine the medical herbalist will take into account the possibility of pregnancy. Such treatment should only be undertaken by a registered medical herbalist who is thoroughly trained in this area.
What is polycystic ovarian syndrome?
Polycystic ovarian syndrome (PCOS) refers to the development of many small follicles or multiple cysts in one or both ovaries, and is a result of hormone imbalances. It typically begins in the late teens or early twenties and has a genetic component, although lifestyle and nutrition are considered factors in the worsening of the condition.
Some of the symptoms associated with polycystic ovarian syndrome are erratic ovulation and menstrual periods and infertility. The hormonal imbalances may also cause growth of facial hair (or hair growth on the chest, abdomen, thumbs and toes) or male pattern baldness and thinning hair, as well as acne or oily skin. This is due to the excess production of the male hormone testosterone.
Other symptoms may include the accumulation of fat in the abdominal area, which increases the risk of metabolic disorders such as glucose intolerance, diabetes and heart disease. An increase in the hormone insulin (frequently referred to as insulin resistance) is responsible for this accumulation of fat around the midrift. About 40 percent of women with PCOS are overweight or obese and have higher insulin levels, when compared with non-PCOS women who had similar quantities of abdominal fat(2).
In forty percent of women with PCOS there are also high levels of luteinising hormone (LH). LH stimulates the growth of follicles within the ovaries.
In addition to our female hormones, we naturally produce male hormones within our ovaries and adrenal glands. Excess adrenal production of male hormones has been found to be present in about 20 percent of Caucasian women and 30 percent of Negroid women(1) with PCOS.
The normal ovarian cycle
Under normal circumstances, ovulation occurs once a month around the middle of your monthly cycle. During the first half of the cycle the egg develops within a tiny follicle and is released around day 14 at ovulation. Each month a number of follicles start to develop but normally only one goes onto ovulate, the rest degenerate and are reabsorbed by the body(4).
The development and maturation of eggs is under our hormone control. Following each menstrual period, the master gland in the brain called the pituitary, releases follicle-stimulating hormone (FSH) and luteinising hormone (LH). FSH and LH stimulate the growth of ovarian follicles and direct the ovary to produce an active form of oestrogen called oestradiol, which causes eggs to mature. LH stimulates the ovaries to produce male hormones which are converted to oestrogen within the ovaries, and once an egg is mature triggers ovulation. In the normal situation only tiny amounts of testosterone (the male hormone) enter the blood stream because most is converted to oestrogen within the ovary (4).
Once ovulation occurs, the ruptured follicle called the corpus luteum, secretes progesterone which prepares the lining of the uterus for implantation of the fertilised egg. If pregnancy does not occur, the corpus luteum degenerates and stops producing progesterone and the menstrual period follows. If the egg is fertilised and pregnancy occurs, the corpus luteum continues to produce hormones until the placenta is ready to take over its hormone-producing duties.
Where does it go wrong in PCOS?
There are a number of hormone imbalances in women with PCOS that start in the ovaries. Ovarian production of active cyclical oestrogen (required for the maturation of the egg) and called oestradiol is reduced. There are also excessive levels of male hormones, which under normal circumstances would be converted to oestrogen. This imbalance predisposes to the development of many immature cystic follicles within the ovary.
As well as not enough active cyclical oestrogen (oestradiol) produced in the ovaries, there is too much production of non-variable oestrogen (oestrone), which is produced in fat tissue where it is converted from testosterone. This non-variable oestrogen is insufficient to produce ovulation. Fat cells in those who are overweight also have a role to play in insulin resistance and perhaps PCOS. Marked weight gain is believed to be a forerunner of PCOS and weight reduction improves this condition.
Sex hormone binding globulin (SHBG) is a carrier protein produced in the liver that binds to both free oestrogen and testosterone circulating in your bloodstream, controlling activity of these hormones. Levels of SHBG are frequently reduced in those with PCOS as a result of excess weight and increased testosterone levels. The end result of SHBG binding with available active oestrogen is a further reduction in oestradiol required for egg development and ovulation, and more ‘free testosterone’ which produces masculinising effects such as acne and male-pattern hair growth and balding(7). The menstrual cycle also ceases; when ovulation doesn’t occur, progesterone is not produced by the corpus luteum, so there is no build up of uterine lining to shed.
Excess weight gain is usually the forerunner of hormonal changes that turn a symptom-free polycystic ovary condition into a full blown syndrome(7), although there maybe a number of other triggers in genetically susceptible women, for example thyroid and adrenal irregularities. Fat tissue is able to convert male hormones into a form of oestrogen called oestrone, levels of which increase when a woman is overweight. This leads to chronically high and non-variable levels of oestrogen which is very different to the fluctuating cyclical levels produced within the ovary and needed for ovulation. In PCOS ovarian oestradiol production is chronically low(7).
Detecting hormone irregularities
Keeping a menstrual diary enables hormone irregularities to be observed. Taking the basal temperature orally each day and charting throughout the monthly cycle can detect ovulation and can help determine the availability of progesterone. This slight but detectable rise in temperature (which is taken first thing in the morning on awakening), is associated with progesterone secretion and has been shown to be reliable 77 percent of the time (8).
Blood and saliva tests can also indicate hormone imbalance. For an accurate indication of progesterone levels the blood test is best taken on day 21 of the menstrual cycle and for the ratio of LH to FSH day 2 is the most accurate. LH is usually only a little higher than FSH, but if the LH to FSH ratio is greater than 2, it maybe indicative of PCOS when combined with PCOS-type symptoms. Prolactin levels and ‘free and total testosterone levels’ are also checked; sometimes only the free testosterone level is raised. Sex hormone binding globulin is often decreased in women with PCOS. Apart from diagnosis these tests can also be used to gauge response to treatment in addition to the symptoms experienced. Other tests may include: thyroid and adrenal function and an ultrasound of the ovaries which will show a pearl necklace type of arrangement of ovarian cysts in those with PCOS.