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Treating the Type of PCOS

By Dr. Kate Dudek

PCOS is not a single condition, with a simple list of symptoms. It presents in multiple forms, with varying symptoms, of varying severity. This makes treating the condition very challenging because not all patients will respond in the same way to the same treatment.

The first step has to be to accurately diagnose PCOS; ultrasound scans are insufficient and should be used alongside blood tests. Ultrasounds will identify cysts on the ovaries and blood tests can measure the levels of circulating hormones, including luteinising hormone and testosterone. Elevation of both of these hormones can be a marker of PCOS.
Rule number one is that not everyone with polycystic ovaries will have PCOS and, conversely, not everyone with PCOS will have polycystic ovaries. Confusing? Definitely, but if you consider the symptoms rather than the condition, a suitable treatment regime can be instigated, personalised to each patient.

Insulin resistance
Many patients who experience ovulatory abnormalities (either an absence of ovulation, or irregular cycles) will also experience metabolic symptoms. The most common of these is insulin resistance, which can affect up to 70% of patients with PCOS. The body produces more insulin to compensate and this increased insulin impedes ovulation and stimulates the ovaries to produce an excess of the male sex hormone testosterone. Patients with this type of PCOS are often borderline diabetic and frequently overweight.
The best way of managing the associated symptoms of this form of PCOS are via lifestyle modifications and reduced sugar intake. Studies have shown that a 5% loss of weight can regulate the menstrual cycle and improve fertility. The oral contraceptive pill is widely used in the management of PCOS, but is not recommended for those who have insulin resistant PCOS as it can impair insulin sensitivity. Dietary supplements can improve the symptoms of insulin resistant PCOS; magnesium and Vitamin E have been found to reduce serum insulin levels as well as reducing hirsutism, which is one of the main signs of hyperandrogenism.  

Pill-induced/post-pill PCOS
The oral contraceptive pill was initially developed to prevent pregnancy; it does this by blocking ovulation and reducing the levels of oestrogen and progesterone. As such, it is often prescribed to help women deal with heavy periods and some of the symptoms of endometriosis.  
The problem some women face is that they continue to have abnormal ovulation for months, or even years, after they finish treatment and this can become a form of PCOS. Not all researchers agree with this terminology, but impaired fertility after the pill is a real concern. Fortunately, it is usually a temporary condition and herbal remedies have been shown to have some beneficial effects. Naturopathic doctors can use the levels of circulating hormones to determine which herbal treatments are most likely to be beneficial on a case by case basis. Peony & liquorice and chaste berry (Vitex) are two examples.

Inflammatory PCOS
It is widely accepted that PCOS has an inflammatory component. When serum levels are measured, patients with PCOS test positive for a number of common inflammation markers (C-reactive protein, interleukin-18 and raised white blood cell counts). Inflammation also has a strong association with the development of insulin resistance and women with PCOS are predisposed to other inflammatory conditions, including cardiovascular disease.
Inflammation can impede ovulation and cause an increase in male hormone release from the adrenal gland. These are two of the main contributory factors leading to a PCOS diagnosis.
Environmental toxins (plastics and pesticides) and inflammatory foods (wheat, dairy and sugar) regularly cause an immune response. An alarming number of everyday products, including household cleaning agents and personal care items, are also endocrine disruptors, which cause hormonal disturbances and can affect fertility.
Taking a holistic approach to therapy and minimising exposure to irritants in the environment and diet can alleviate some of the symptoms of PCOS as well as minimising hormonal disruptions. A healthy diet with no processed foods and limited alcohol will also help, and careful supplementation can be beneficial. Magnesium, in addition to reducing insulin levels, has anti-inflammatory activity and, therefore, is one of the most useful supplements to take. Zinc and probiotics can be used effectively to treat inflammation of the gastrointestinal tract.
These therapies are particularly effective for patients who show other signs of immune dysfunction, such as headaches, frequent infections and skin complaints.

Hidden-cause PCOS
This category of PCOS is used to classify all women who do not fall into one of the above three categories. Usually in these cases, the symptoms of PCOS are due to a single factor blocking ovulation. Examples include too much soy, thyroid disease, a vegetarian diet (zinc deficiency), iodine deficiency and artificial sweeteners. Soy is anti-oestrogenic and can block ovulation. Thyroid hormone, zinc and iodine are all required by the ovaries and deficiencies in all, or any, of them can cause ovulatory problems. Artificial sweeteners interfere with normal insulin signalling, increasing the likelihood of developing insulin-related complications.
The advantage to this form of PCOS is that once the cause is identified, treatment is usually straightforward. Solving the underlying problem should rectify any PCOS symptoms.

There is nothing to say that somebody with PCOS cannot fit into more than one of the above categories, for example there is a particularly strong association between inflammation and insulin resistance. It is also important to note that symptoms can change over time, for example, PCOS in children may cause an early puberty and metabolic symptoms such as insulin resistance. With adulthood, hyperandrogenism and anovulation might become the more obvious effects. This means that optimum treatment may change over time.

The take home message is that by starting to identify the reasons for your PCOS symptoms, you should be able to find better ways of managing them.        

Sources:

  • Duleba, A J, and A Dokras. “Is PCOS an Inflammatory Process?” Fertility and Sterility, vol. 97, no. 1, Jan. 2012, pp. 7–12., doi:10.1016/j.fertnstert.2011.11.023.
  • El Hayak, S, et al. “Poly Cystic Ovarian Syndrome: An Updated Overview.” Frontiers in Physiology, vol. 7, 5 Apr. 2016, p. 124., doi:10.3389/fphys.2016.00124.
  • Marshall, J C, and A Dunaif. “Should All Women with PCOS Be Treated for Insulin Resistance?” Fertility and Sterility, vol. 97, no. 1, Jan. 2012, pp. 18–22., doi:10.1016/j.fertnstert.2011.11.036.
  • Norman, R J, et al. “The Role of Lifestyle Modification in Polycystic Ovary Syndrome.” Trends in Endocrinology and Metabolism, vol. 13, no. 6, Aug. 2002, pp. 251–257.
  • Pasquali, R, et al. “The Impact of Obesity on Reproduction in Women with Polycystic Ovary Syndrome.” BJOG, vol. 113, no. 10, Oct. 2006, pp. 1148–1159., doi:10.1111/j.1471-0528.2006.00990.x.
  • Patel, S. “Polycystic Ovary Syndrome (PCOS), an Inflammatory, Systemic, Lifestyle Endocrinopathy.” The Journal of Steroid Biochemistry and Molecular Biology, vol. 182, Sept. 2018, pp. 27–36., doi:10.1016/j.jsbmb.2018.04.008.
  • Shokrpou, M, and Z Asemi. “The Effects of Magnesium and Vitamin E Co-Supplementation on Hormonal Status and Biomarkers of Inflammation and Oxidative Stress in Women with Polycystic Ovary Syndrome.” Biological Trace Element Research, 18 Dec. 2018, doi:doi: 10.1007/s12011-018-1602-9.
  • Briden, L. “Treatment for 4 Types of PCOS. Treat the Cause.” Lara Briden - The Period Revolutionary, 16 May 2014, www.larabriden.com/treatment-for-4-types-of-pcos-treat-the-cause/.
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