An approach from a naturopathic doctor for PCOS
Polycystic ovarian syndrome is a relatively common condition affecting females, often associated with complaints of changes in body composition, irregular menstrual periods, hair deposition in a male pattern, infertility, and pain. We get many patients from the greater Vancouver and Richmond area searching for a naturopath for PCOS.
The condition is generally diagnosed when two of the following is found: polycystic ovary seen on ultrasound, irregular menstruation, clinical indications or laboratory indications of excess male hormones.
Symptoms of PCOS
Patients often have difficulty controlling their weight. They may have signs of male hormone excess, including facial hair growth, while they may have thinning or loss of their regular hair. They often have irregular menstrual cycles, usually far apart, but can include prolonged bleeding as well. They may have adult acne. In addition, they can have more generalized symptoms related to the mechanisms of PCOS, including fatigue, cravings, mood swings.
Sex hormone changes in PCOS
The common underlying hormone changes and communication between the brain and the ovaries in PCOS lead to a hormone called LH (luteinizing hormone) to be produced in much more frequent pulses. This leads to an excess of testosterone.
The increased testosterone leads to decreased ovulation, increased abdominal and organ fat, increased fat cell size, increased circulating fats like cholesterol. The effects of an excess of testosterone on the liver can again cause fat infiltration, and lead to increased glucose production.
What are some of the causes of PCOS that a naturopathic doctor might discuss?
The actual causes are unknown, although treatment is usually focused on early diagnosis as well as weight loss when applicable to reduce the complications of things such as diabetes and heart disease. There are noncontributing factors, which a naturopathic doctor approaching PCOS would investigate. This would include insulin excess or insulin resistance, balancing of the hormones especially elevated levels of the male hormones, while dealing with and trying to manage some of the possible complications such as infertility, miscarriage, hypertension, fatty liver infiltration, sleep apnea, and diabetes.
There are different theories behind the development of PCOS. This includes exposure to hormone disruption in the prenatal period, as well as prenatal sugar imbalances and insulin resistance. There is some evidence for genetic susceptibility as well. These are often though as triggers, or susceptibility factors.
Factors that make PCOS continue typically include insulin resistance, imbalances in communication between the brain and ovary, and fat accumulation in organ and muscle. The excess male hormone / androgens that persist can contribute to increased insulin resistance, inflammation, and even poor impulse or dietary control. The androgens themselves can make areas of the brain less sensitive to estrogen and progesterone.
Metabolic approaches
The majority of women with PCOS have very clear underlying metabolic changes, usually with respect to any insulin resistance. This can be quantified by the measurement of the fasting insulin, alongside fasting glucose. While both these levels may not be out of range, we calculate a HOMA ratio which can then give us indications as to the level of insulin sensitivity that is present.
The higher the HOMA ratio the more likely, generally, that interventions aimed at improving insulin sensitivity would help with the PCOS symptoms, as well as of course with weight loss.
Some of the symptoms that are often associated with this metabolic pattern include an apple shaped body, with excess weight concentrated typically around the abdomen. There are often things such as intense sweet cravings, alongside the difficulty in losing weight.
If her testing does indicate that insulin resistance is a part of the picture, therapies that the naturopath would consider for PCOS would include specific diets, sometimes including intermittent fasting, ketogenic diets, or a general anti-inflammatory diet. There are botanicals and nutrients that also seem to have some effect on insulin resistance, and often times the discussion will include supplementation or measurement of things such as inositol, niacinamide which may be useful, or herbal therapy such as berberine.
Ozone therapy, likely may be useful in the management of insulin resistance as well. One study in diabetic foot ulcers not only found improvement in the ulcer itself but found reduction in plasma glucose concentrations in the ozone therapy group not in the control group.
Usually, a combination of herbal, micronutrient, specific exercise prescriptions, diet, and possibly ozone therapy is used in combination when we suspect insulin resistance as part of the picture for PCOS. We have the elevated HOMA ratio, this can be used to follow progress and ensure that the therapeutics are working for the patient.
Hormonal balance as part of the naturopathic doctor’s approach to PCOS
Progesterone plays a very important role in PCOS. With proper assessment and balance of progesterone, the brain can become less prone to secretion of excess LH (which then leads to excess androgen or male hormone production) - effectively breaking the cycle of PCOS.
Progesterone may also help to offset some of the cardiovascular risk from the metabolic changes in PCOS. It may help with bone health, which can be a concern when normal ovulation cycles are not happening.
Cyclic progesterone therapy can be a mainstay of treatment alongside metabolic interventions mentioned above. This can help to expose the body to healthy levels of progesterone, rather than the chronic deficiency state that is seen in PCOS and thought to perpetuate the PCOS.
Most naturopathic approaches to PCOS that look at progesterone therapy borrow from the work and publications of Dr. Jerilynn Prior at UBC. Approaches can include 14 day off protocols as well as 18 day off options. The 18 day off options may be better at avoiding the suppression of natural ovulation, and is often used in patients trying to get pregnant, who often still have a menstrual period but find that it is usually late.
In some cases, continuous progesterone therapy is discussed if there is menorrhagia (abnormally heavy or long periods) if there is limited response to initial cyclic therapy. It can be useful when trying to balance against excessive estrogen levels.
Hormone testing for monitoring therapy in PCOS
Prior to treatment, and to establish if there is a clear hormone imbalance, estrogen and progesterone are typically measured to establish ratios. Usually, this is checked around 1 week before an expected period, or 5-7 days after ovulation. When a patient is on progesterone therapy, testing is often repeated again after 3 months.
Optimal thyroid hormone balance in PCOS
There are various studies showing that suboptimal thyroid function is associated with PCOS. One study in 2019 found TSH levels above 2.5 to be associated with the hyper-androgen state:
Background: Infertility and dyslipidemia are frequently present in both women with polycystic ovary syndrome (PCOS) and subjects with thyroid dysfunction. Limited study regarding the association between thyroid stimulating hormone (TSH) level and phenotypes in euthyroid PCOS women. We aimed to determine whether the variation of TSH level associates with phenotypes in euthyroid PCOS patients. Methods: Cross-sectional study including 600 PCOS and 200 age, body mass index (BMI), and thyroid autoimmunity-matched Chinese women from Renji hospital, Shanghai Jiaotong university during January 2010 and August 2018. The anthropometric and serum biochemical parameters related to TSH, thyroid autoimmunity, lipid profiles, and sex steroids were detected. Results: The TSH level is higher in (2.29 ± 1.24 vs. 1.86 ± 0.90 mu/L, p < 0.001) in PCOS than controls. In euthyroid PCOS patients, TSH, TG, TC, LDL-c, and apoB level increased from non-hyperandrogenism (nonHA) to HA group (all p < 0.05). TSH level is positively associated with TG, apoB, free T, FAI, and negatively associated with apoA (all p < 0.05). The percentage of HA increased from TSH level (57.93% in TSH < = 2.5 group vs. 69.46% in TSH > 2.5 mU/L group, p = 0.006). HA phenotype is increased with TSH level independently of age, BMI, WC, LDL-C. Besides, in multivariate logistic regression analysis TSH and TG significantly associated with HA phenotype. Conclusions: Higher TSH level is associated with increased prevalence of HA phenotype independent of age, BMI and thyroid autoimmunity in euthyroid PCOS.
Another earlier study in 2009 found that a TSH above 2, was associated with insulin resistance in PCOS patients:
Background: The aim of this study was to evaluate the association between thyroid function, reflected by thyroid-stimulating hormone (TSH) levels, and insulin resistance (IR) in 337 women suffering from polycystic ovary syndrome (PCOS).
Methods: Clinical, metabolic and endocrine parameters were obtained and an oral glucose tolerance test was performed, with calculation of IR indices. The association between thyroid function and IR was evaluated with classification analysis using logistic regression and 10-fold cross-validation to identify a possible TSH threshold for IR. Parameters were then compared between women above and below the TSH threshold using two-sample tests. One-way analyses of covariance were performed to explore whether the impact of TSH on IR is independent of other variables.
Results: A TSH cut-off value around 2 mIU/l had the best sensitivity and specificity for identifying women with IR. Women with TSH >or= 2 mIU/l were younger, had a higher body mass index (BMI) and were more insulin-resistant compared with women with TSH < 2 mIU/l. This effect of TSH on IR was independent of age and BMI.
Conclusions: In women with PCOS, a significant association between thyroid function, as reflected by TSH >or= 2 mIU/l, and IR was found and the association appeared to be independent of age and BMI.
There are different mechanisms suggested. One is that low thyroid function has been found to decrease the proteins (sex hormone binding globulin or SHBG) that inactivates testosterone. There may also be issues with weight gain, poor metabolism that perpetuates the PCOS cycle.
The naturopathic doctor would typically look at optimizing thyroid function with nutrients such as selenium, vitamin D, zinc, B12, as well as hormone replacement if indicated. There would be a role for dietary assessment, as there is emerging evidence that iodine excess even in small amounts (as well as deficiencies) can damage the thyroid. The damage is mediated through free-radical and oxidative mechanisms, so an assessment of oxidative stress and antioxidant discussed would be part of the naturopathic approach to PCOS.
Detoxification and PCOS
While exposure to hormone disrupting chemicals in the prenatal period can be associated with PCOS, a naturopathic approach will often still take into account current toxicity levels. There is some data to suggest that ongoing exposure to hormone disrupting chemicals can contribute to the PCOS picture. While it is unclear if detoxification support would be enough to directly affect PCOS, it likely would reduce the overall burden that the body has to manage with, allowing more homeostasis and balancing by the body to occur.
Heavy metal assessment and treatment may be part of the picture as well. One study of 84 PCOS patients compared to 70 controls, found that certain heavy metals were associated with the PCOS group compared to controls, as well as specific metals being associated with insulin resistance. While again it is unclear if removal of these metals is enough as a primary treatment, reduction of the body burden again is part of removal of obstacles to cure.
Overall
A naturopathic doctor’s approach for PCOS would include often the multiple factors above. We typically would not investigate all factors at once, but based on the history and exam, and in discussion with the patient, investigate what makes the most sense to them and us. If you would like to have a naturopathic work up and approach for PCOS, please call our office to book an appointment with Dr Tawnya Ward, ND.