PCOS treatment and therapy are always individualized, compassionate, skillful and resourceful. As a holistic doctor who specializes in PCOS, Dr. Gary Goldman will formulate a treatment plan individualized to your symptoms, your concerns, and your goals. Make an appointment today.
What are the Symptoms of PCOS?
Polycystic ovary syndrome (PCOS) is a common and complex condition found in 8 to 13 percent of women. The condition is characterized by menstrual irregularities, infertility secondary to anovulation, virilization, metabolic syndrome, and increased weight.
There is substantial variability in the severity of symptoms among affected individuals. Common presenting symptoms include menses that are irregular, infrequent, or even absent. This is caused by irregular or absent ovulation, which in turn can impair the ability to achieve a pregnancy.
Masculinizing changes in skin and hair are common. Known as virilization or hirsutism, the changes in underlying hormone production of androgens can cause acne, oily skin, and coarse hair growth in areas typically found in men. Some women will experience crown hair loss, or alopecia. Other skin changes indicative of associated insulin resistance are acanthosis nigrans, a darkly pigmented velvety skin around the neck, as well as numerous skin tags around the neck and under arms.
How do you diagnose PCOS?
The diagnostic criteria for PCOS have changed over time, but it has always been a diagnosis of exclusion; once other sources of pathology have been ruled out, we then consider PCOS. A 1990 National Institute of Health consensus paper required the presence of both chronic anovulation, and clinical or biochemical signs of increased androgens.
The Rotterdam Criteria are used far more commonly to diagnose PCOS. Proposed in 2003, they require irregular or absent ovulation, clinical or biochemical signs of hyperandrogenism, and sonographic evidence of polycystic ovaries (two of the three criteria are needed). The presence of PCOS type ovaries without concurrent ovulatory dysfunction or androgen excess is insufficient to make the diagnosis of PCOS.
The Rotterdam sonographic criteria consist of the presence of 12 or more follicles within each ovary, each with a diameter of two to nine millimeters, or an ovarian volume of 10 cubic centimeters or greater. Subsequent authors have suggested more stringent criteria of up to at least 26 follicles. Adolescents normally have many follicles; thus, sonography may not be used in establishing their diagnosis.
How do you test for PCOS?
Diagnostic lab studies should begin with thyroid stimulating hormone, prolactin and early am 17-hydroxy-progesterone to exclude other disorders.
Increased ovarian androgens can be assessed with elevated levels of free and total testosterone. Elevations in adrenal androgens can be found by evaluating DHEAS. Sex hormone binding globulin (SHBG) levels should also be measured as this modifies the biologic activity of circulating androgens.
Lack of menstrual periods, or anovulation, can be confirmed by checking for progesterone levels that remain consistently low. Alternatively, this can be evaluated with static basal body temperatures. Erratic cycles should be followed with a menstrual diary.
Follicle stimulating hormone (FSH) and luteinizing hormone (LH) levels are sometimes altered. Women with PCOS can make an insufficient amount of FSH and have a normal to high normal amount of LH. This can produce an increased LH to FSH ratio of greater than three when measured on day three of an ovulatory cycle.
Anti-Mullerian hormone (AMH) is often elevated in women with PCOS. This compound is made by the multitude of small follicles in the ovary.
Diabetes can be a part of PCOS. To exclude diabetes, a fasting insulin and fasting glucose should be measured. A Hemoglobin A1c will provide information on long-term sugar control, while a Fructosamine level will reflect shorter term glucose control. A two-hour oral glucose tolerance test can also be considered.
Serum lipids should be carefully monitored, including at a minimum fasting cholesterol, HDL, LDL and triglycerides. Since PCOS syndrome is a highly inflammatory state, elevated hs-CRP levels can be used to follow systemic inflammation.
In addition to lab studies, a good physical exam remains essential. In particular, the exam should note blood pressure, weight, body mass index (BMI), waist and hip circumferences as well as the waist to hip ratio, and evaluation for excess body hair growth or loss of hair on the head.
What causes PCOS?
The etiology of PCOS remains enigmatic. It appears that almost any insult can contribute to the condition. A major insult is poor lifestyle, especially a lack of exercise, increased weight and a highly inflammatory, high carbohydrate diet. This promotes increased insulin production and leads to insulin resistance.
Family history is another contributor. Various genetic alterations in the form of single nucleotide polymorphisms (SNPs) have been reported.
When a woman with PCOS who has increase androgens becomes pregnant, she may may expose her fetus to these hormones during crucial times of fetal development. Female offspring exposed to increased levels of excess maternal testosterone have a substantially increased risk of developing PCOS.
Recently several researchers have proposed the origin of PCOS lies in neuroendocrine alterations, especially a decrease in the neurotransmitter GABA.
Other metabolic derangements may also contribute. Reduced liver production of Sex Hormone Binding Globulin (SHBG) can cause increased levels of active androgens. Vitamin D deficiency appears to be a potentially reversible contributor to PCOS. Altered microbiome with excess pathologic flora has been reported in PCOS patients, raising the question if probiotic supplementation can help to restore a healthy metabolism. Autoimmune adrenal insufficiency may also be a cause.
Lastly, a variety of toxins have been reported to produce a PCOS phenotype in animal models. In particular Bisphenol A, which inhibits aromatase can produce a hyperandrogenic state.
How do you treat PCOS?
Therapy for PCOS should be tailored to each patient’s particular concerns and goals. Therapy should encompass all of the metabolic issues that have been identified, seeking to improve the patient’s symptoms and well as to address the potential long-term consequences of metabolic dysregulation.
Abnormal body hair, acne, oily skin, loss of hair on your head
The first step in an evaluation of hyperandrogenism is a good history, examination and lab evaluations. Exclude other reasons for hyperandrogenism such as high ovarian or adrenal hormones, elevated prolactin, abnormal thyroid hormone levels, or elevations in 17-hydroxy-progesterone.
Traditional first line treatment is the Oral Contraceptive Pill (OCP), also called the Birth Control Pill. OCPs increase SHBG, which binds free testosterone rending it inactive. They also reduce LH secretion and testosterone. No particular OCP has been demonstrated to have an advantage over others to treat hyperandrogenism.
Insulin-sensitizing agents, such as Metformin, result in lower insulin levels, lower oxidative stress and lower androgen production. Other benefits include improved glucose regulation and improved ovulation – thus attention to contraception is important. Uncommon concerns include diarrhea, lactic acidosis, hypoglycemia and hyperkalemia.
Anti-androgens such as Spironolactone act primarily by blocking the ability of testosterone to bind to androgen receptors in the skin. Flutamide and Finasteride are two additional anti-androgens which should be used with caution due to their teratogenic potential. A novel agent is topical Eflornithine for treatment of facial hair growth. The outcome data for Eflornithine plus laser hair removal is better than for laser alone.
The value of lifestyle modifications cannot be overestimated. Multiple studies have demonstrated the wide-ranging benefits of weight loss, improved diet and increased exercise in the 80 percent of women with PCOS who are overweight. The most effective diet for PCOS is a low Glycemic Index, low carbohydrate, high fiber, high vegetable diet. Enlisting a nutritionist, an exercise trainer and a health coach can provide the emotional support and expert instruction necessary to produce a sustained change in lifestyle.
A Functional Medicine approach to hyperandrogen PCOS must start with a complete review of the person, her overall health and medical history. Attention must be paid to the potential contribution of thyroid and adrenal dysfunction.
Adrenal overstimulation from chronic stress causes an outpouring of cortisol and DHEA which can worsen PCOS. In addition to the testing discussed above, I recommend testing for TSH, T3, T4, rT3, antithyroid antibodies, DHEA and 4-sample salivary cortisol along with Vitamin D levels. I often use a deeper analysis of sex hormone metabolism with the Dutch Complete test.
Based on test results and the patient’s symptoms and goals, I often recommend a variety of natural supplements that can help to reverse the metabolic derangements often seen in PCOS.
Missing periods, Irregular periods, and Anovulation
Too often I have had the opportunity to consult with young women whose periods have become erratic or have stopped all together. For some, the lack of cycles has them worried about their general state of health. Others desire to achieve a pregnancy and are appropriately concerned about infertility.
Irregular or absent menses in the reproductive age group should be carefully evaluated before assuming the cause is PCOS. A basic evaluation should begin with a careful menstrual history. A transvaginal ultrasound should also be performed to evaluate the endometrium as well as the ovaries.
Erratic or absent ovulation leads to menstrual irregularities. Anovulation can be confirmed by checking for progesterone levels that remain consistently low. Alternatively, this can be evaluated with static basal body temperatures. Erratic cycles should be followed with a menstrual diary.
An evaluation should take into account a particular woman’s circumstances. Pregnancy should be ruled out with a urine test. Premature ovarian insufficiency can be explored by looking for a substantial elevation of follicle stimulating hormone (FSH) and luteinizing hormone (LH). In the setting of anorexia, or extreme loss of body fat seen in athletes, very low FSH and LH levels can be found.
A pituitary microadenoma is considered in the setting of visual field changes, headaches, and bilateral milky nipple discharge; a prolactin level should be checked even if the woman is asymptomatic.
Thyroid dysfunction is another common reason for menstrual irregularities. A TSH, T3 and T4 form the basic evaluation, and further testing can be individualized including a reverse T3 and anti-thyroid antibodies.
Various medications can inhibit ovulation. If the patient recently stopped using the birth control pill, the internal monthly clock can be altered, resulting in prolonged amenorrhea. Recent use of progestins can have a prolonged impact on menstrual regularity. Steroid use, antipsychotics, chemotherapy, antidepressants, blood pressure medications and some allergy medications can also alter menstrual regularity.
Once other diagnoses have been excluded and PCOS has become the de facto diagnosis, the traditional therapy depends on the woman’s current desire to achieve a pregnancy.
The most commonly prescribed, expeditious traditional therapy is the oral contraceptive pill (OCP), especially if there is also evidence of hyperandrogenism. OCP’s will protect the endometrium from adverse build-up. They help to stimulate bone growth by increasing the amount of bone matrix. The birth control pill also helps to prevent premature aging of blood vessels. OCP’s also increase SHBG, which helps to diminish hyperandrogenic symptoms when present.
If the woman desires pregnancy, then therapy is typically ovulation induction. In years past this had been performed by administering clomiphene citrate (Clomid), subsequently with Metformin, and then with Metformin combined with Clomid. More recently, Letrozole, an aromatase inhibitor, has been demonstrated to have the highest rates of success for inducing ovulation in the PCOS patient, and in 2018 the American College of Obstetricians and Gynecologists recommended this as first line therapy.
If all of these orally administered medications fail, then we consider injectable gonadotropin therapy. Patients with PCOS have a higher rate of ovarian hyperstimulation syndrome with gonadotropin therapy, thus low dose protocols are often used.
The functional medicine practitioner has a deeper selection of tools available to help achieve the patient’s goal of regular ovulation, which can include lifestyle management, exercise, diet, weight loss and various supplements, all customized to the needs of each particular patient.
PCOS can present in any number of ways, often causing distress to the patient. A thoughtful and compassionate approach to evaluating and treating each person based on her particular symptoms and goals is often helpful.
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