Anna, age thirty, has never had regular menstrual periods. She has gone as long as one year without a period. In the past, she had been told that missed periods are fairly common in young women, and had been advised to take birth control pills to regulate her cycles.
But Anna has other symptoms, too—obesity, persistent acne, and excess facial hair growth. And she and her husband have been trying to conceive a child for three years. A visit to a fertility expert leads to extensive testing and eventually a diagnosis of polycystic ovarian syndrome (PCOS). Anna is told that if she wants to get pregnant, she will need to take fertility drugs. But she’s worried about the possible long-term side effects of these drugs, and wants to better understand her condition so that she can explore possible alternatives.
Anna (not her real name) is like an estimated 6 to 10 percent of American women who have PCOS—and they are having trouble getting help. At a meeting in October 2000 with the National Institutes of Health, patient activists for PCOS told researchers that the average woman with the disorder sees at least four doctors over a period of nine years before she gets treatment. The activists asked the assembled doctors to direct research into the role of diet and other alternative therapies for PCOS. They also believe it’s crucial to investigate the relationship between PCOS and psychological health, including eating disorders.
PCOS and its symptoms were first described in 1935. But the cause of the condition is still unknown, and diagnosis and treatment are difficult because the syndrome is so complex, and because it is so variable from woman to woman.
The name of the syndrome comes from its most common characteristic: multiple cysts, or follicles less than one-half inch in diameter, on both ovaries. These small cysts are the result of eggs that only partially develop within the ovary.
Women with PCOS may miss periods or menstruate infrequently or irregularly, or their periods may be prolonged or abnormally heavy. They may fail to ovulate; they may experience weight gain. And they may see the kind of facial and other excess hair growth that tends to occur with hormonal abnormalities. They may have acne or chronically oily skin. The hair on their heads may thin.
Worse yet are the potential complications of PCOS. Women with the syndrome are at higher risk for impaired glucose tolerance and diabetes. They are also at greater risk of hypertension and heart disease, endometrial cancer, and possibly breast cancer. This is why, if you suspect that you may have PCOS, a thorough diagnostic workup is essential. Other diseases, such as some tumors of the ovaries or ad renal glands, defects in adrenal gland functioning, thyroid dysfunction, and premature menopause can produce some of the same symptoms as PCOS.
Your diagnostic workup should include a physical exam, pelvic ultrasound, and a variety of blood tests. Findings that point to PCOS may include multiple ovarian cysts, elevated levels of androgens (male hormones such as testosterone), an elevated level of luteinizing hormone (without the usual surge of this hormone that initiates ovulation), and evidence of insulin resistance, including elevated insulin levels. Because PCOS is a highly variable disease, not all women will produce these test results.
What's happening hormonally
Here’s what appears to go wrong in cases of PCOS. For some reason, the ovaries produce excess androgens. In some cases, these male hormones are not converted into estrogens as they are in healthy women. The culprit may be a deficiency of a specific converting enzyme the body uses in this process. For other women, excess estrogen may be present, mostly in the form of estrone, a particularly strong type of estrogen.
These elevated hormone levels interfere with the normal monthly fluctuations of luteinizing hormone, made by the pituitary gland. Luteinizing hormone induces ovulation; in healthy women it’s low in the early part of the menstrual cycle and spikes to a high level at ovulation, then drops again. In women with PCOS, luteinizing hormone may be constantly high, and the spike that provokes ovulation doesn’t happen—so ovulation doesn’t happen and conception can’t happen.
Cysts form on the ovaries from failed ovulation; over time, this causes multiple cysts. The absence of ovulation leads to infertility and sometimes to low progesterone levels.
It’s the abnormal hormone levels that contribute to increased risk of chronic disease. Excess androgens increase the risk of heart disease, hypertension, and elevated cholesterol. Elevated estrogen levels combined with low progesterone contribute to an increased risk of endometrial cancer that’s about three times the risk for other women. Some studies suggest women with PCOS may suffer an increased risk of breast cancer as well.
There is growing evidence that insulin resistance and an increased risk of glucose intolerance and diabetes are strongly associated with PCOS. In insulin resistance, the cells resist the action of insulin to allow glucose into the cells. This causes the pancreas to produce more insulin in an attempt to overcome the resistance. Elevated insulin levels may be why the ovaries produce greater-than-normal amounts of male hormones in some women with PCOS. There is also a high incidence of eating disorders in women who develop PCOS; 30 to 60 percent of women with the disorder are overweight. Some studies suggest that modest weight loss can correct the problem and lead to normal menstruation in some women.
A study on rats with PCOS produced some interesting data. In these animals, PCOS can be induced by alterations in stress and exposure to light. Although it’s unclear whether these factors influence the syndrome in human women, it has been observed that PCOS is more common in urban women who have high stress levels. There is no question that stress and other emotional factors influence menstrual cycles. It’s also known that light-dark cycles may influence hormones and menstrual cycles.
Based on what doctors and researchers know now, it’s likely that PCOS has more than one cause and that a variety of factors may influence its development.
Lifestyle treatments for PCOS
Gynecologists generally prescribe birth control pills, synthetic progesterone, androgen-blocker drugs, and other hormone-affecting medications for women with PCOS. The fertility drug Clomid is generally used when a woman with PCOS wants to become pregnant. Although such pharmaceuticals can be helpful in regulating the menstrual cycle and decreasing symptoms, they do have potential side effects. More important, none of them address the underlying causes of PCOS.
With the exception of a few studies using Traditional Chinese Medicine (TCM) formulas, there is very little research on using herbs to treat PCOS. Herbalists rely on their understanding of the physiology of the syndrome and their knowledge of the action of herbal remedies to make good choices. Here are some possibilities.
Vitex (Vitex agnus-castus). Although no studies have yet looked at vitex specifically to treat PCOS, it is a logical and appropriate choice. Vitex is an excellent hormone-balancing herb that works at the pituitary level. Clinical experience suggests that it can help normalize menstrual cycles in a variety of conditions and may even treat infertility due to hormone imbalances.
To take vitex in a tea, simmer 1 teaspoon of the dried berries in 1 cup of water for 10 minutes. Drink 2 to 3 cups per day. To take it in a tincture or glycerite, take 1/4 to 1 teaspoon two or three times per day. Vitex is also available in standardized extract capsules; a typical dosage is 225 to 500 mg of extract standardized to 0.5 percent agnuside, taken two times per day.
Side effects: Rarely, gastrointestinal upset and nausea, headache, rashes, fatigue, and hormone-related symptoms have been reported.
Saw palmetto (Serenoa repens). Usually thought of as an herb for the male reproductive system, saw palmetto works by blocking testosterone receptor sites and inhibiting the conversion of testosterone to a more potent form. For women with PCOS, it’s possible that these actions may decrease the effects of excess androgens in the body. A typical dosage for standardized capsules is 160 mg, twice a day, for a product that contains 85 to 95 percent fatty acids and sterols. Saw palmetto has no reported side effects.
Formulas containing white peony root (Paeonia lactiflora). This herb from the Chinese medical tradition has been shown to bind weakly to both estrogen and androgen receptor sites in human cells. In animal studies, it’s been noted to inhibit testosterone synthesis by the ovaries. Several scientific studies from Japan and China have evaluated herbal treatments that include white peony root for women with PCOS. The studies evaluated various changes in laboratory values (decreases in luteinizing hormone, decreases in the ration of luteinizing hormone to follicle-stimulating hormone, decreases in blood sugar and insulin levels, and decreased testosterone) as well as whether ovulation was induced. Overall, these studies suggest that the formula may help women with PCOS. Some infertile women became pregnant during the course of the studies, and in one study, 70 percent of the women who had not been ovulating did so. Such formulas may be worth investigating if you want to conceive a child but are not ovulating. (Some of the study results may have come from the other herbs in the formula or the synergy among them, so it may be worthwhile to consult a qualified TCM practitioner if you want to try Chinese remedies for PCOS.)
A typical dose of white peony root is 2 to 6 g per day of dried root, simmered in water for 20 minutes; or 1/4 to 1/2 teaspoon of tincture or glycerite two to three times per day. There have been no side effects for white peony root reported in literature.
Licorice (Glycyrrhiza glabra). This herb was used in combination with peony in the studies discussed above. It may work by its hormone-balancing effects, by its tonic effects on the adrenals, or by its ability to promote overall liver health. The liver is instrumental in clearing excess hormones from the body, so keeping tabs on its functioning is important for women who have PCOS.
A typical dose of licorice in tea would be two to three cups per day, with 1 teaspoon of dried, chopped root simmered for 10 minutes. If you prefer to take a tincture, a typical dose is 1/4 to 1/2 teaspoon, two to three times per day. Rarely, taking licorice can produce diarrhea. In excessive doses, it can cause elevated blood pressure, elevated sodium, low potassium, and fluid retention. Don’t take it if you have high blood pressure, heart disease, kidney disease, or are pregnant.
Liver-support herbs. Herbs to look for in detoxification formulas (or to try if you can’t take licorice) include turmeric (Curcuma longa), schisandra (Schisandra chinensis), milk thistle (Silybum marianum), and dandelion root (Taraxacum officinale). Detoxification herbs help the liver continue to clear excess androgens and estrogen. Dill seed, caraway seed, and the peels of citrus fruits also stimulate detoxification and can be included regularly in the diet.
Herbs for stress management will be helpful when stress and anxiety are part of a woman’s overall conditions. There are two groups of herbs that are useful in such cases: adaptogens and nervines. Adaptogens, such as Siberian ginseng (Eleutherococcus senticosus) and schisandra balance the adrenal glands and help the body adapt to stress. Various nervines—herbs that promote relaxation—might be appropriate depending on the situation. American skullcap (Scutellaria lateriflora) is an excellent choice for women whose hormone imbalances are accompanied by mood swings. Stronger relaxing nervines, such as kava (Piper methysticum), valerian (Valeriana officinalis), or passionflower (Passiflora incarnata) can be used if anxiety or insomnia is present. A cup of good old chamomile tea (Matricaria recutita) might also be beneficial. For these herbs, doses will vary widely depending on the situation; your best bet is to read and follow the manufacturer’s directions, or consult a qualified herbal practitioner.
Hunter, M. H., and Sterrett, J. J. “Polycystic ovary syndrome: it’s not just infertility.” American Family Physician 2000, 62(5): 1079–1088.
Sakai, A., et al. “Induction of ovulation by Sairei-to for polycystic ovary syndrome patients.” Endocrinology Journal 1999, 46(1): 217–220.
Takahashi, K., and Kitao, M. “Effect of TJ-68 (shakuyaku-kanzo-to) on polycystic ovarian disease.” International Journal of Fertility and Menopausal Studies 1994, 39(2): 69–76.