Evaluation and Treatment of Polycystic Ovarian Syndrome


 

What is Polycystic Ovarian Syndrome?

Polycystic Ovarian Syndrome (PCOS) is the most common endocrine disorder in women, affecting an estimated 5-10% of all women of reproductive age. It usually starts at the time of puberty, with an increased incidence of menstrual abnormalities, acne, facial hair, weight gain and infertility. If not controlled, it can lead to increased risks of uterine cancer, cardiovascular disease and a 7 fold increase in type 2 diabetes. For women trying to conceive a child, PCOS is a serious, common cause of infertility - nearly half of all female factor infertility cases can be traced to PCOS. When pregnancy occurs, the rate of first trimester miscarriage is as high as 30-50%.


Insulin resistance is a common finding in women with PCOS. The excess insulin causes abnormally high levels of male hormone production from the ovary, leading to acne on the face, breasts, back and abdomen, oily skin, and sometimes male pattern hair loss. Insulin also decreases the amount of sex-hormone-binding globulin from the liver, which means there is excess free androgen (male hormone) in the circulation. This causes negative cosmetic effects, but also affects blood pressure, and increases cardiac risk factors, with a decrease in HDL (good cholesterol) and an increase in LDL, triglycerides and VLDL (unhealthy cholesterol).


Treatment of PCOS

The goals of treatment include control of insulin resistance and abnormal glucose levels, treatment of elevated lipids, treatment of anovulation and symptoms of androgen excess (acne and oily skin), prevention of abnormal uterine bleeding and treatment of infertility.

Given the complex endocrine and metabolic nature of PCOS, the treatment plan should be integrative, and may include insulin-sensitizers (glucophage, (Metformin), ovulation stimulants (clomiphene, letrozole or injectable gonadotropins), nutritional supplements (chromium, cinnamon, ginseng, alpha-lipoic acid), dietary changes (low glycemic diet) and behavior modification (increased exercise and mind-body medicine for stress relief such as biofeedback, yoga, meditation, music therapy) with allow many women to overcome PCOS and conceive a child naturally, while reducing the risk of miscarriage. Acupuncture calms sympathetic tone and may stimulate ovulation. Combinations of anti-insulin medications have been studied and may improve weight loss and ovulation.

Recent studies have investigated the use of N-acetylcysteine (NAC) in women with polycystic ovary syndrome (PCOS). N-acetylcysteine has been shown to have anti-inflammatory properties and is converted to glutathione, the main anti-oxidant in the body. Eight studies with a total of 910 women with PCOS were randomized to NAC or other treatments/placebo. Women with NAC had higher odds of having a live birth, ovulating , and getting pregnant as compared to placebo. However, women with NAC were less likely to have a pregnancy or ovulation as compared to metformin. There was no significant difference in rates of miscarriage, menstrual irregularity, acne, hirsutism, and adverse events, or change in body mass index, testosterone, and insulin levels with NAC as compared to placebo. The authors concluded that NAC showed significant improvement in pregnancy and ovulation rate as compared to placebo but longer follow-up periods are needed to examine clinical outcomes such as live birth rate.

Inositol is a member of the B-vitamins and a component of the cell membrane. It is believed that inositol increases the action of insulin in women with PCOS, thereby improving ovulation, decreasing testosterone, and lowering blood pressure and triglycerides. In a recent study, 25 women received inositol for six months. Twenty-two out of the 25 (88%) patients had one spontaneous menstrual cycle during treatment, of whom 18 (72%) maintained normal ovulation. A total of 10 pregnancies (40% of patients) were obtained. Generally, inositol is well tolerated but can cause nausea, fatigue, headaches and dizziness. No interactions with herbs or supplements are known. There is concern, however, that high consumption of inositol might exacerbate bipolar disorder. Inositol is sold as myo-inositol (most common in the U.S.) or d-chiroinositol. Dosage is 200 to 2,000 mg daily. Ovasitol is sold online and in health food stores, but may not have both components. Theralogix makes a high quality supplement with the appropriate ratio of myo-inositol to d-chiroinositol, important for egg health.

What next? Women who undergo treatment for PCOS but are still unable to conceive naturally are good candidates for assisted reproductive technologies, including IUI and IVF, and often experience high pregnancy success rates. Fertility drugs cause an increased risk of multiple birth, and ovarian hyperstimulation where the ovaries produce excess egg sacs during therapy. This can lead to fluid draining into the abdomen, blood clotting, and may equire draining of fluid or hospitalization.

 

Assisted Reproductive Technology - Blausen.com staff

PCOS patients are challenged by physical and emotional distress. There is not one simple treatment strategy for all patients, as each patient has her own unique combination of symptoms and disease manifestation. A complete evaluation to rule out other organ system problems (adrenal, thyroid, uterine, tumors) is necessary before treatment to improve the likelihood of a successful response and reduce risks of complications. An integrative approach often improves results.

There is ample evidence that physical activity may help in the prevention and management of type 2 diabetes. It is important that patients with this chronic disease remain regularly active. Both aerobic and resistance training appears to help with glucose control and weight loss, and reduce the risk of future diabetes and heart disease.

 


References

  1. PCOS Nutrition. Nutritionist driven website with great information about diet, exercise, supplements, and nutritionist consultation.
  2. Exercise and Type 2 Diabetes. Sheri R. Colberg, PHD, FACSM, Ronald J. Sigal, MD, MPH, FRCP(C), Bo Fernhall, PHD, FACSM, Judith G. Regensteiner, PHD, Bryan J. Blissmer, PHD, Richard R. Rubin, PHD, Lisa Chasan-Taber, SCD, FACSM, Ann L. Albright, PHD, RD, and Barry Braun, PHD, FACSM
  3. N-Acetylcysteine for Polycystic Ovary Syndrome: A Systematic Review and Meta-Analysis of Randomized Controlled Clinical Trials. Divyesh Thakker, Amit Raval, Isha Patel, and Rama Walia
  4. Myo-inositol in patients with polycystic ovary syndrome: A novel method for ovulation induction. Papaleo E, Unfer V, Baillargeon J P, et al.

 

Resources

 

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