What is PCOS?

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PCOS stands for Polycystic Ovarian Syndrome. It is a hormonal imbalance that affects as many as 1 in 10 women in their menstrual years. PCOS is characterized by 2 out of 3 of the following symptoms according to the Rotterdam Criteria: irregular menstrual cycles, elevated androgen levels, and ovaries that display many cysts due to follicles not being released for ovulation.

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Common Symptoms of PCOS

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• Irregular menstrual cycles

• Difficulty getting pregnant

• Difficulty with weight management

• Acne or oily skin

• Hair growth in unwanted places (face, stomach, back)

• Hair loss or thinning of hair on the head

 

Overview of a Normal Menstrual Cycle

 

Before jumping into the causes of PCOS, it is good to have an understanding of a normal menstrual cycle and how the reproductive hormones work with each other under normal conditions.

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There are 4 phases of the menstrual cycle:

• Menstruation

• Follicular Phase

• Ovulation

• Luteal Phase

 

Menstruation

The first day of menstruation is called Day 1 of the cycle. This is when the thickened lining of the uterus (the endometrium) is shed in the absence of a fertilized egg.

 

Follicular Phase

The first half of the cycle (day 1-14) is called the follicular cycle. This is when immature eggs (follicles) in the ovary grow in preparation for ovulation. The growth of the follicles happens in response to a hormone called FSH (follicle stimulating hormone) that is released by the pituitary gland. FSH causes the ovary to produce 5-20 follicles in the ovary, each containing an immature egg. One egg will usually mature and grow bigger than the others, and the others will be resorbed back into the tissue.

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Ovulation

During the follicular phase, estrogen rises in response to the developing follicles. This sends a message to the hypothalamus to release GnRH (gonadotropin releasing hormone), which prompts the pituitary to release a surge of LH (luteinizing hormone) at mid-cycle. Around day 14, the mature egg is released from the ovary due to the surge of LH. It travels into the fallopian tube and then the uterus.

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Luteal Phase

The second half of the cycle (day 14-28) is called the luteal phase. After the egg has been released, the ruptured follicle transforms into the corpus luteum. The corpus luteum produced progesterone and small amount of estrogen. These hormones continue to thicken the uterine lining in preparation for a fertilized egg. If the egg is not fertilized, this causes a drop in progesterone, which signals the uterus to start shedding its lining, and menstruation begins the cycle again.

 

What causes PCOS?

 

The exact cause of PCOS is unknown, but multiple factors including insulin resistance, chronic low-grade inflammation, genetics, and environmental and dietary influences are thought to contribute to imbalances of the reproductive hormones.

 

Hormonal imbalances common in PCOS

• Progesterone may be low

• Estrogen may be high

• LH may be high

• LH:FSH ratio may be high

• Elevated androgens, such as testosterone, androstenedione, dehydroepiandrosterone (DHEA), and DHEA sulfate (DHEAS)

• Insulin levels may be high

• SHBG (Sex Hormone Binding Globulin) may be low

 

Why do these hormonal imbalances cause irregular cycles?

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These hormonal imbalances lead to an inhibition of ovulation, which becomes self-perpetuating.  

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• Low progesterone: When ovulation does not occur, there is no corpus luteum to produce progesterone. Progesterone and estrogen levels influence the hypothalamic pulse of GnRH. Low progesterone results in the hypothalamus having a fast pulse of GnRH (gonadotropin releasing hormone).

• This fast pulse of GnRH causes the pituitary to release less FSH during the follicular phase and more LH in general.

• Lower FSH will perpetuate the production of many small follicles during the follicular phase that do not have the ability of to mature properly.

• Chronically elevated LH will inhibit ovulation, since ovulation is dependent on a big surge of LH at mid-cycle. Without ovulation, there is no corpus luteum to produce progesterone during the luteal phase, and the cycle repeats.

• Elevated androgens: Additionally, elevated androgens appear to cause PCOS cycle irregularity, as well as result from it in a vicious cycle.

 

Contributing Factors to PCOS hormonal imbalance

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• Insulin resistance is thought to be a key contributor to PCOS. Elevated insulin causes LH to be chronically elevated. This prevents ovulation from being stimulated properly. Elevated LH also increases androgen production by the ovary. Elevated androgens in turn contribute to insulin resistance.

 

• Excess androgen production by the ovaries may be stimulated in PCOS for a variety of reasons:

  • Elevated LH

  • Genetic and environmental factors

  • Deficiency in the enzyme that transforms testosterone to estrodiol in the ovary. If this is the case, the decreased estrodiol levels will influence the pulse of GnRH release by the hypothalamus, which in turn will affect FSH and LH levels, growth of follicles and ovulation.

  • Excess androgens will also induce inflammation and increase insulin resistance, leading to increased androgen production by the ovary in a vicious cycle.

 

• Low grade inflammation

  • Chronic low-grade inflammation is known to be a key contributor to PCOS.

  • Glucose has been shown to trigger MNCs (mononuclear cells), which are part of the immune system, in women with PCOS to secrete proinflammatory cytokines.

  • The proinflammatory cytokine TNFα (tumor necrosis factor alpha) is involved with insulin resistance and has also been shown to stimulate androgen production.

  • Low grade inflammation is often associated with excess gut permeability at the small intestine (also known as leaky gut).

 

• Adipose tissue: There is a vicious cycle between adipose tissue (mainly in the form of visceral body fat that surrounds internal organs) and androgen production.

  • Abdominal obesity and insulin resistance stimulate the ovaries and adrenals to produce more androgens.

  • Excess androgen production, in turn, increases obesity, inflammation, and insulin resistance, which again stimulates androgen production.

  • Androgens also increase the size of adipose cells.

 

• Low SHBG (Sex Hormone Binding Globulin)

  • Elevated insulin lowers the production of SHBG (Sex Hormone Binding Globulin) by the liver. SHBG serves to bind androgens, but when it is low, there will be more free circulating testosterone and other androgens.

 

• Sympathetic Nervous System

  • FSH and LH secretion by the pituitary are controlled by the pulse of GnRH from the hypothalamus. Since the hypothalamus is also responsible for the stress response, elevated stress could be changing the pulse rhythm at the level of the hypothalamus and be a causative factor in the dysregulation of pituitary output of FSH and LH.

 

My Approach as an Herbalist & Nutritionist

 

For PCOS, it is crucial address the underlying causes of the condition for every individual. No two cases of PCOS are alike. Because it is so prevalent in the population, lifestyle, environment, and diet must be considered.

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PCOS can be a vicious cycle without negative feedback to interrupt it, but starting somewhere, anywhere, can sometimes make a big difference, just by interrupting some aspect of the cycle.

 

The majority of people with PCOS will benefit from interventions that modulate inflammation, blood sugar balance, and stress, with individualized herbal medicines to support hormonal balance.

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How Can Herbs Help?

 

PCOS is not a one-size fits all condition. There are multiple underlying factors that contribute to the imbalance, and these should be determined first. After a thorough assessment, herbs can be used to interrupt the vicious cycle of insulin resistance, irregular cycles, low-grade inflammation, and hormonal imbalance. With that in mind, herbal support can look very different from one person to the next.

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The herbal actions that may be helpful in PCOS are:

• Hormone modulator

• Blood sugar modulator

• Adaptogen

• Nervine

• Antiinflammatory

• Antioxidant

• Antiandrogenic

• Hepatic

• Alterative