In my Acupuncture practice on Cape Cod, Massachusetts, one of the most frequent conditions that I treat in young women, is Polycystic Ovarian Syndrome. This is not surprising given that it affects 9-18% of women of reproductive age (Lin et al, 2019). Otherwise known as Stein-Leventhal Syndrome or by its acronym PCOS, it is characterized by long, anovulatory menstrual cycles, and a host of other uncomfortable symptoms such as excess hair growth, acne, and mood disorders. This article will discuss PCOS from both a western biomedical and traditional Chinese medicine perspective; and attempt to offer natural solutions for its treatment.
Background:
In a typical menstrual cycle, ovulation occurs when a mature ovarian follicle releases an egg. In women with PCOS, none of the ovarian follicles become mature, and therefore an egg is not released. Instead, these immature follicles develop a fluid filled sac, called a cyst. These follicles produce large amounts of estradiol, which inhibits FSH release, and prevents further follicular development (Davis & Segars, 2009).
Women with PCOS are frequently plagued with insulin resistance, and difficulty in losing weight. Nearly half have a BMI in the obese range (Lin et al., 2019). The higher levels of insulin cause theca cells in the ovaries to increase androgen production, which in turn stops follicular development and ovulation (Davis & Segars, 2009). The excess androgens cause hirsutism, mood disorders, and androgenic alopecia. Other symptoms include difficulty becoming pregnant, pelvic pain, patches of darker velvety skin known as Acanthosis nigricans, and heavy periods when they do arrive.
Diagnosis:
PCOS is usually diagnosed by the Rotterdam criteria of having two out of three of the following clinical findings: No ovulation; high androgen levels (causing excess facial or body hair, and acne); and ovarian cysts detected by pelvic ultrasound (Teede et al., 2010). Other diagnostic criteria include fewer than 9 periods per year, or amenorrhea with lack of ovulation; and an elevated ratio of LH:FSH (2:1 or 3:1 on blood work taken on day 3 of the menstrual cycle).
Although the presence of polycystic ovaries is one of the diagnostic criteria for PCOS, they are also found in 8-25% of women not having the syndrome (Polson et al, 1988). In fact, 14 percent of women on the birth control pill have polycystic ovaries, and ovarian cysts are a common side effect of the IUD (Clayton et al, 1992).
Other conditions associated with PCOS are: Type 2 diabetes, obesity, sleep apnea, heart disease, mood disorders, and endometrial cancer. Similar symptoms may also be found in: Adrenal Hyperplasia, Hypothyroidism, and high blood levels of Prolactin, and these conditions may need to be ruled out before a diagnosis is made.
Etiology and Treatment:
The exact cause of PCOS is unknown, but it seems to arise due to a combination of both genetic and environmental factors. Risk factors include obesity, lack of physical exercise, and a family history of PCOS. Currently there is no cure, but symptoms may be managed through lifestyle change.
Healthy diet, exercise, and weight loss all are effective in regulating cycles and managing symptoms. In addition, patients are typically given a combination of medications to reduce androgens, regulate the menstrual cycle, and lower insulin resistance. Unfortunately, many of these medications come with their own host of side effects.
Birth Control Pill:
If pregnancy is not desired, the birth control pill is typically the first choice of treatment, as it mimics a regular menstrual cycle, and helps to offset the excess androgens. However, it can carry with it a higher risk for blood clots, heart attack and stroke; and additionally cause weight gain; fluid retention; nausea; mood changes; chest pain; stomach pain; and headache (Anderson, 2018). Moreover, once the pill is discontinued, PCOS symptoms return.
Spirinolactone:
Another medication often taken in combination with the birth control pill is Spironolactone. It is a potassium sparing diuretic that is able to reduce excess androgens. It is not used in women desiring pregnancy, as it could feminize a male fetus. Other side-effects include irregular bleeding, nausea, vomiting, stomach cramps, and diarrhea (Sinha, 2018).
Metformin:
Metformin, a medication often used in the treatment of type 2 diabetes, is used to help regulate insulin levels in PCOS patients. It may be used with the birth control pill, or in women who desire to become pregnant. In this case, it is combined with Clomiphene Citrate. Side effects of Metformin include diarrhea, nausea, dizziness, and vomiting (drugs.com, 2019).
Clomiphene Citrate:
Clomiphene Citrate is used to stimulate ovulation in women who would like to become pregnant. Its side effects include ovarian hyper-stimulation syndrome, abnormal vaginal or uterine bleeding, breast tenderness, headache, nausea, vomiting, diarrhea, pelvic pain, and an increased likelihood of delivering multiples (Cunha, 2019).
Need for a Natural Solution:
With all of the side effects inherent with these medications, and the lack of a proper cure, it’s no wonder that many women are looking for a more natural solution that tackles the root of the problem.
Traditional Chinese Medicine (TCM) offers a few such natural solutions, with the use of Acupuncture and Herbal Medicine to help regulate cycles, promote ovulation, and manage some of the side effects such as depression, weight gain, and acne. In addition, both Traditional Chinese and Modern Western biomedicine recommend a low glycemic, whole-foods diet, rich in fruits, vegetables, and whole grains, with a healthy amount of daily exercise.
TCM perspective:
From a Chinese Medicine perspective, PCOS falls into the categories of Kidney yang deficiency, Dampness / phlegm, Liver Qi stagnation, and Blood stagnation or deficiency (Shen et al., 2013).
Kidney yang deficiency is also associated with hypothyroidism, low progesterone, low adrenal function, and infertility. These patients may present with cold body temperature, fatigue, long menstrual cycles, and lower back ache with their periods.
The pattern of Dampness may occur as a result of the weakened kidney yang function, or from an excess of damp producing foods such as sugars, simple carbohydrates, and dairy. Over time, dampness may congeal into “phlegm”. It corresponds to symptoms such as excess weight, type 2 diabetes, fatigue, foggy-headedness, and digestive disturbances such as bloating and diarrhea.
The liver in Chinese Medicine, is responsible for the smooth flow of the menstrual cycle, and with regulating the hormones. Stuck liver Qi may be attributed to an excess of stress, which manifests in depression, anger and irritability; tension of the jaw and trapezius muscles; headaches; cramping with ovulation and menstruation; breast distention and pain; and PMS.
Blood stagnation is found in women who experience large clots with their period, and sharp and stabbing cramps. Blood deficiency on the other hand, presents as anemia, scanty menstrual periods, pale complexion, tiredness, poor memory, and possibly spots in the visual field.
Chinese Herbal Medicine:
According to a nationwide population-based study in Taiwan, the most common herbal formula used to treat PCOS was Jia Wei Xiao Yao San (Lin et al, 2019). This formula is made up of: Bupleurum, White Peony Root, Dong Quai, Attractylodes, Poria, Licorice, Mint, Poria, Tree Peony root bark, and Gardenia fruit, and is used to regulate menstrual problems, mood, and anxiety issues. Some of its ingredients – White Peony root and Dong Quai, have been found to improve insulin sensitivity, and Licorice root is useful for inhibiting androgen synthesis (Shen et al, 2013). Other commonly used formulas include: Wen Jing Tan, Gui zhi fu ling wan, Dang gui shao yao san, and Shao fu zhu yu tang. Additionally, the formulas Liu Wei di huang wan, and Si wu tang, were found to lower the LH:FSH ratio with Si wu tang also lowering testosterone levels, and Liu Wei di huang wan increasing estradiol. This is likely due in part to the phyto-estrogens found in many of these formula’s ingredients (Liu et al., 2013). Another research study looked at the formula Tiangui Fang as an adjunct to Metformin, and found that it lowered testosterone and insulin better than metformin alone (Shen et al., 2013).
Common single herbs added to formulas include: Yi Mu Cao (motherwort), Xiang Fu (cyperus), Tu si zi (dodder seed/ cuscuta), Dan shen (salvia militorrhiza / red sage), Da huang (rhubarb root), Yan Hu Suo (cordalis rhizome), Xu duan (teasel root), Hong hua (safflower flower), Nu zhen zi (privet fruit), and Du Zhong (eucommia) (Lin et al., 2019).
A few single herbs also have isolated compounds which have been studied and found to have an anti-androgenic action, These include Dan Shen – Salvia militorrhiza, Huang Qin – Scutillaria, and Chamomile. Others like San qi (notoginseng), Ze Lan (bugleweed), and Ze Xie (Alisma), were found to help induce ovulation (Shen et al., 2013).
Chamomile:
This common weed, most often found in teas which promote relaxation, may be useful in treating PCOS. In a randomized controlled trial , 80 women were given either 370mg of chamomile 3 times per day for three months, or a similarly dosed starch capsule (Akbarzadeh et al., 2018). Those who received the chamomile had significantly lowered testosterone levels (p=.017). No significant differences were found in lipids, triglycerides, or LH/FSH levels. Chamomile was also studied in rats and found to induce recovery from PCO, as well as increasing dominant follicles and creating “better endometrial tissue arrangements” (Farideh, 2010).
Huang Qin – Scutillaria:
A compound Baicalin was isolated from the herb Huang Qin and given to rats which had PCOS. It was found to reverse high androgens, normalize ovaries, and cause a return of a normal menstrual cycle (Yu et al., 2019). It successfully lowered serum free testosterone and total testosterone, FSH, LH, Progesterone, and Estradiol. It also inhibited serum insulin levels, decreased body weight, and suppressed inflammatory cytokines. Researchers speculate that it’s action could be due to its effect on reducing insulin resistance. In my clinical practice, I use this herb to help patients with Diabetes 2.
Acupuncture:
Although more large-scale research is needed, Acupuncture has been shown to modulate the hypothalamic pituitary ovarian axis (HPA axis), which affects menstrual cycles. It also stimulates the pituitary beta-endorphin which inhibits Gonadotropin releasing hormone pulse generator, and pituitary LH. In short, it may reduce ovulatory dysfunction, and decrease the secretion of ovarian androgens in PCOS (Jo et al., 2017).
When compared in research to Metformin, Acupuncture improved menstruation rates, and lowered testosterone and LH levels more than Metformin alone (Jo et al., 2017). It also improved ovulation rates when compared to groups receiving no treatment. The ideal dosage for Acupuncture to treat PCOS is two or more times per week for several months to a year. However, in my clinical experience, if Acupuncture is used with Chinese Herbal Medicine, results may be achieved with less frequent treatments.
Diet and Exercise:
Regular exercise and improvement in nutritional quality, even without significant weight loss, has been shown to improve reproductive and endocrine function, as well as the cardio-metabolic risks present in patients with PCOS. Nutritional suggestions include: reducing fat to less than 30% of total calories, with an emphasis on mono-unsaturated fat sources; lowering the glycemic index of carbohydrates consumed with an emphasis on lower carbohydrate foods such as lean proteins and low-glycemic vegetables (think green); and distributing calories between several meals with fewer snacks and calorie containing beverages.
One systematic review (Moran et al., 2013), looked at the dietary composition in the treatment of polycystic ovarian syndrome, and found that a low glycemic diet was associated with greater menstrual regularity, and was able to lower insulin resistance, fibrinogen, and cholesterol, as well as increase quality of life. Higher protein composition was found to lower depression, while a high-carbohydrate diet was responsible for more free-androgens, weight gain, and hunger. Nevertheless, regardless of dietary composition, weight loss from any diet was able to improve the PCOS presentation and alleviate symptoms. A good goal is a 5-15% reduction in body weight.
Supplements:
A 2017 systematic review (Pundir), found that myo-inositol and d-chiro-inositol help to regulate the menstrual cycle, and improve ovulation.
Vitamin D deficiency was found to play a part in the development of metabolic syndrome, and therefore could be useful in treating the insulin resistance that occurs with PCOS (Kruel-Poel et al., 2013). More data is needed to confirm whether supplementation is an effective treatment.
Closing Remarks:
PCOS is a very common and frustrating disorder for many young women. It causes many health issues including infertility, and has no known cure. Nevertheless, there are a multitude of promising natural solutions which help to alleviate symptoms, and bring about a return to a regular and smooth menstrual cycle.
Pia Mezzacappa Lic.Ac. MAOM: Pia is an Acupuncturist and herbalist specializing in women’s health and fertility. In practice for over 10 years, she received her Master’s Degree in Acupuncture and Oriental Medicine from the New England School of Acupuncture. Currently, she is working towards her doctorate in Acupuncture and Chinese Medicine at the Pacific College of Health and Science. In addition to private practice, she has worked as a full-time researcher for four years at the Athinoulas A. Marino Center of the Massachusetts General Hospital, investigating the use of Acupuncture on Carpal Tunnel Syndrome using functional MRI and Magneto-encephalography(MEG). This research has been widely published in biomedical journals, including the neurology journal Brain. She lives with her husband and two children on Cape Cod.
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