PCOS Doctor: Hormones, Nutrition and Herbs

By Dr. Nicole Sundene

Female Hormone Specialist

PCOS or Polycystic ovarian syndrome is a common Women's Health Hormone condition that is improved best by working with a Naturopathic Doctor in my humble opinion after twenty three years of experience working in both prescription and natural Women's Health.

My treatment for PCOS patients as a Holistic Hormone Doctor almost never require medications or birth control pills. There are alternatives to birth control pills and medications for PCOS patients that we will discuss today as well as the risks vs the benefits of many common medications prescribed for PCOS.

PCOS causes hormonal imbalance such as the disruption of estrogen, testosterone, DHEA, cortisol, and progesterone levels. As a result, various clinical symptoms develop, including PMS, Estrogen Dominance, abnormal heavy periods, irregular periods, no period or amenorrhea, anemia, infertility, and a high risk for cancer of the breast, uterus and ovaries when the hormone imbalance is left untreated.^{[1, 4, 7]}

PCOS is common among women of childbearing years, between 15 to 44 years of age. PCOS is affecting 6% to 12% of US women aged between 15–49 years. A research study estimated the worldwide prevalence of PCOS between 6% and 26%. Women with a family history of PCOS or who have diabetes, insulin resistance, or obesity are at higher risk of developing PCOS. ^{[1, 2]}

Symptoms of PCOS

PCOS symptoms vary from mild to severe and mostly appear in the late teens or early 20s. It involves a few or many of the below symptoms. ^{[1, 3, 7, 8]}

• Abnormal Menstruation: Irregular periods, light periods, spotting, heavy periods, painful cramping, and totally absent periods are hallmark symptoms of PCOS. Heavy periods often accompany PCOS.
• Infertility: Women with PCOS show difficulty in conceiving, failure to ovulate, or are completely infertile.
• Polycystic Ovaries: Numbers of cysts develop in the ovaries, ovaries get enlarged, and fail to function properly. Also, in some cases, it is accompanied by pelvic pain or pain in the lower abdomen.
• Hirsutism: Excessive facial hair growth and dark body hair are common in PCOS. Hair grows mainly on women's chest, face, back, or buttocks, due to increased level of circulating testosterone and adrenal gland hormones. Also, tthinning hair, hair damage, or hair loss from the head can occur.
• Weight gain: Mainly due to accumulation of fats around the belly in an apple distribution, and too much insulin production causes weight gain. Weight gain then furthers the hormone imbalance and estrogen dominance which then causes more weight gain. Weight loss for PCOS is possible to accomplish yet requires a dedicated long term approach with nutrition changes and herbal supplements to correct the hormone imbalance.
• Skin conditions: PCOS disrupts skin integrity impacting a wide variety of dermatology conditions such as hormonal acne, cysts, rashes, eczema, psoriasis, and cystic acne from overactive sebaceous glands. Hormone imbalance drives these dermatology disorders and they do not improve until the hormone imbalance is corrected. Too much insulin, estrogen, testosterone, DHEA, and cortisol are generally behind the dermatology condition in PCOS patients. Skin discoloration can also occur, usually in the form of darkened pigment in the armpits, groin, neck, and under the breast.

Types of PCOS

Research studies categorized PCOS into many types based on the clinical symptoms and causes responsible for the development and progression. While mainstream prescription medicine manages all PCOS patients with oral birth control pills, metformin and spironolactone, these treatments often fail when we do not have the correct treatment for the correct type of PCOS. Determining which category of PCOS the patient falls in should be done first and foremost prior to implementing any PCOS treatments. The main PCOS types include: ^{[8, 9]}

• Insulin-resistant PCOS: This is the most common PCOS type caused by pollution, smoking, high sugar, overweight, and excess fat content resulting in high insulin level in the body or insulin resistance. Moreover, the high amount of insulin secretion prevents ovulation and favors the production of testosterone.
• Inflammatory PCOS: The inflammation-induced PCOS is characterized by ovulation suppression, hormonal imbalance, and Hyperandrogenemia (HA). Stress, environmental toxins, and inflammatory dietary like gluten are responsible for inflammation-induced PCOS.
• Hidden-cause PCOS: This is considered the simpler PCOS type caused by multiple factors, including thyroid disease, iodine or zinc deficiency (ovaries need iodine and zinc), poor diet, and artificial sweeteners.
• Pill-induced PCOS: The second most common type of PCOS is caused by birth control pills administration that suppresses ovulation. Ovulation may not resume until months or even years after women with PCOS stop their birth control pills. Please note that birth control pills do not "cure" PCOS. They simply mask the symptoms. A woman with PCOS does not have a "real period" on birth control pills, but an artificial period caused by the withdrawal from synthetic hormones. This should be the last option parents entertain when they have a teenager with PCOS as suppressing a young woman's hormone production may impact their development and mental health. I also find this a generally ineffective treatment plan for PCOS when many better natural alternatives exist.
• Other types include the adrenal PCOS and Lean type of PCOS.

New research on PCOS presented the following subgroups of PCOS patients based on genetic markers. ^{[8, 9]}

• Reproductive group: Patients with high Luteinizing Hormone & Sex hormone-binding globulin level, plus low Body Mass Index and Insulin levels.
• Metabolic group: Patients with high Body Mass Index, glucose level & insulin level, plus low Luteinizing Hormone & Sex hormone-binding globulin level.  
• Indeterminate group: Patients who did not fit into the above two groups.

PCOS Diagnosis and its Criteria

Diagnosis of PCOS should begin with the patient's questioning, family history, physical examination, and checking the other endocrine parameters. As PCOS is a complex disease, so research studies devised criteria for its diagnosis; based on the presence of hyperandrogenism, ovulatory dysfunction, and polycystic ovaries. The presences of any two clinical symptoms in the patient among the hyperandrogenism, ovulatory dysfunction, and polycystic ovaries are necessary for PCOS diagnosis. ^{[2, 3]}

The clinician should consider the menstrual history, weight gain or loss, and cutaneous findings such as excessive hair, acne, alopecia, and dark patches for hyperandrogenism confirmation. Plus, ask and evaluate the presence of ovulatory dysfunction via oligomenorrhea and amenorrhea. Also, check for the other medical complications associated with PCOS. ^[3]

Other lab approaches to assist the diagnostic criteria to include; ^{[2, 3]}

• A pelvic examination to check any overgrowth in ovaries or uterus.
• Blood test evaluation is performed to evaluate abnormal endocrine function or hormone levels. Also, to analyze the level of cholesterol, insulin, and triglyceride for comorbidities of PCOS.
• Ultrasound or other imaging techniques is used for confirming the presence of abnormal follicles in the ovary (12-25 or more, the 25 follicles of 2 to 9 mm in diameter) or any other uterine or ovary damage.

Medical Complications of PCOS

Women with PCOS are at high risk of developing certain medical complications. These include type 2 diabetes, gestational diabetes, heart disease, hypertension, depression, sleep disorders, eating disorders, anxiety, plaque formation, and stroke. ^[6]

PCOS Treatment Guidelines

Although there is no definite cure for PCOS; however certain kinds of treatment interventions are recommended for resolving PCOS symptoms and complications. These interventions include both pharmacological and non-pharmacological approaches that treat symptoms and regulate normal physiological function. While I do not recommend or prescribe pharmaceuticals for PCOS and do not personally find them effective for managing this condition as a female hormone specialist, I will still discuss the risks and benefits of medications for PCOS. ^{[1, 2, 5]}

Non-Pharmacological approach

Non-pharmacological approaches involve applying electrolysis that passes electric current into the hair follicles, damage them, and arrests hirsutism. ^[3]

Weight loss

Weight loss is considered a gold standard for managing PCOS symptoms as weight loss improves insulin sensitivity, particularly in obese PCOS women. Also, obesity increases the risk of metabolic and reproductive abnormalities associated with PCOS. Weight loss is recommended as the first line of treatment for infertility in obese women with PCOS. Unfortunately, there is no approach for permanent weight loss, and weight decrease relapsed in around 90-95% of patients. However, bariatric surgery significantly sustains and reduces weight in obese individuals. Moreover, a hypocaloric diet also helps weight reduction in women with PCOS. But there is no clear evidence of the positive impact of weight reduction on PCOS symptoms. ^{[2, 3]}

Natural Diet & Lifestyle For PCOS Symptoms

• Improve Carb-Protein uptake as it positively impacts insulin synthesis in the body.
• Add a Mediterranean diet to the meal as it contains olive oil, green vegetables, and fish like tuna and mackerel that provide anti-inflammatory effects.
• Increasing the consumption of fiber will help digestion and bloating.
• Consume supplements such as Iron as it improves hemoglobin and also helps anemia.
• Avoid caffeine and alcohol as it favors insulin resistance.
• Supplementation of Zinc may help the hair loss symptoms.
• Evening primrose oil, calcium, chromium, inositol, cinnamon, Berberine and Vit D intake improve insulin resistance and may reduce pain associated with menstrual cycle irregularities.
• Regular exercise could be beneficial for weight reduction and may improve diabetic symptoms.  

PCOS Medication Treatment

Different classes of medicines are used for the treatment of PCOS complaints. These include;

Metformin: It is an oral anti-diabetic medication that improves insulin resistance and decreases insulin concentration. Mostly, it is recommended as a second-line drug of choice after clomiphene that induces ovulation, lowers serum androgen, and helps menstrual frequency. Moreover, it showed the best results in combination with clomiphene in obese women with PCOS. Side effects associated with the use of metformin include lactic acidosis and gastrointestinal symptoms such as diarrhea, nausea, vomiting, abdominal bloating, flatulence, and anorexia. ^{[1-3, 5]}

Oral contraceptives: Oral contraceptives such as estrogen and progestin therapy help treat PCOS symptoms via inhibition of Luteinizing and androgen hormone secretion, increasing the Sex hormone-binding globulin level, and also act as steroids receptors blocker. The side effects of oral contraceptives include a high risk of thromboembolic events, developing type 2 diabetes, elevated cholesterol and triglyceride level, and may impair insulin sensitivity. Therefore a low dose of oral contraceptives is recommended as the above adverse events are high dose-dependent in high-risk women with PCOS. ^{[1-3, 5]}

Progesterone therapy: Natural progesterone and synthetic progesterone such as Cyproterone acetate and drospirenone provide anti-androgenic properties. Some women with PCOS may need a combination or natural progesterone with an oral contraceptive to treat PCOS. The side effects of progesterone therapy include mood elevation or depression, weight gain, and abnormal periods, heavy bleeding, cramping, and spotting. ^{[1-3, 5]}

Spironolactone: It helps the treatment of excessive hair and acne. However, there are limited studies about its effectiveness. It is advised to use it with caution in women with renal impairment as it aggravates hyperkalemia as a side effect. Also, it is not recommended during pregnancy due to teratogenicity (congenital disabilities). ^{[1-3, 5]}

Please Note: If you do not want to take medications for PCOS and prefer a nutrition and herbal medicine approach then you will be a perfect fit for treating your PCOS. Otherwise, the medicine I use to treat PCOS is nutrition changes, supplements and herbs so there is no point in signing up to work with me if you or your teenager are not willing to make dietary changes. I understand they are hard to do and struggle with them myself, but we at least need to be comitted to making these changes gradually over time to be successful with Naturopathy when treating PCOS symptoms.

If you think you will be able to use Naturopathy and need help diagnosing or treating your PCOS symptoms simply pop over to my SCHEDULE page to treat yourself to a Naturopathic visit!

Dr. Nicole Sundene, NMD

(480) 837-0900

Dr. Sundene is a Naturopathic Doctor in Scottsdale, Arizona, and is considered a Female Hormone Expert  in Women's Health and Bioidentical Hormones. She specializes in Holistic Women's Health for Menopause, Thyroid, Hashimotos, PMS, Perimenopause, Autoimmune, Postpartum, Chronic Fatigue, Depression, Anxiety, Food Allergies, Digestion, Dermatology , Acne, Psoriasis, Eczema and Adrenal Hormonal Conditions. In 1999 she began working for a Hormone Doctor prior to starting Naturopathic Medical School. With over 22 years of experience in both Prescription and Natural women's health and hormones she presents to women the best integrated health solutions for their Chronic Disease. She has been an Herbalist for over 27 years and enjoys teaching women how to use herbs to balance their hormones, nutrition and optimize their health. Dr. Sundene relies on blood testing for her hormone metrics. The hormone testing is covered per the patient's insurance plan and conducted at certain points in the woman's menstrual cycle. To learn more about Hormone Testing for Women Visit: Bioidentical Hormones. Follow Dr. Sundene on Instagram, Twitter and Facebook for more tips on Women's Health, Female Hormones and Naturopathy!

References

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5. Ajossa, S., Guerriero, S., Paoletti, A. M., Orrù, M., & Melis, G. B. (2004). The treatment of polycystic ovary syndrome. Minerva ginecologica, 56(1), 15–26.
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7. Rasquin Leon LI, Mayrin JV. Polycystic Ovarian Disease. [Updated 2020 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459251/
8. Matthew Dapas, Frederick T. J. Lin, Girish N. Nadkarni, Ryan Sisk, Richard S. Legro, Margrit Urbanek, M. Geoffrey Hayes , Andrea Dunaif; “Distinct subtypes of polycystic ovary syndrome with novel genetic associations: An unsupervised, phenotypic clustering analysis” Published: June 23, 2020, https://doi.org/10.1371/journal.pmed.1003132
9. https://thehormonedietitian.com/types-of-pcos/
10. McCartney, C. R., & Marshall, J. C. (2016). CLINICAL PRACTICE. Polycystic Ovary Syndrome. The New England journal of medicine, 375(1), 54–64. https://doi.org/10.1056/NEJMcp1514916
11. Sirmans, S. M., & Pate, K. A. (2014). Epidemiology, diagnosis, and management of polycystic ovary syndrome. Clinical Epidemiology, 6, 1–13.
12. Witchel, S. F., Oberfield, S. E., & Peña, A. S. (2019). Polycystic Ovary Syndrome: Pathophysiology, Presentation, and Treatment With Emphasis on Adolescent Girls. Journal of the Endocrine Society, 3(8), 1545–1573. https://doi.org/10.1210/js.2019-00078