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PCOS 101: Girlfriend, Let Me Break It Down For You Again.


Polycystic Ovarian Syndrome (PCOS) is a disorder that affects approximately 5 million women in the US. Its a complex syndrome that Western Medicine is still trying to fully understand and is typically described as a hormonal disorder that can hinder fertility in multiple ways. Your medical practitioner or acupuncturist can diagnose PCOS based upon a discussion of your symptoms and blood tests. And while continuing to learn more about PCOS, there are things you can do today to help contain its impact on your life using both Eastern and Western Medicine. 

But that's just skimming the surface.  In the words of Lauryn Hill: Girlfriend, let me break it down for you again. Push up those eye glasses, because we're about to go deep. 

What is PCOS? 

PCOS is a collection of symptoms associated with a malfunctioning endocrine system. 

Your endocrine system is responsible for ALL hormone production. And since hormones regulate, oh you know, metabolism, growth and development, tissue function, sexual function, reproduction, sleep, and mood (among other things),  I bet you can guess that PCOS symptoms run the gamut and tend to be a wee bit complex.  

PCOS Presentation: Clinical Signs and Symptoms:

PCOS is characterized as a syndrome rather than a disease because it manifests as a group of signs and symptoms that occur in a variety of combinations in each woman.  Some appear thin, some are overweight, some have excess hair growth, some may have thinning hair, and so on and so forth.

However, classical signs and symptoms include the following: 

-Irregular periods

-Cervical mucus excess followed by limited or no cervical mucus for long stretches of time

-Excessive body or facial hair (hirsutism)

-Male pattern hair loss

-Acne

-Obesity (50% of women with PCOS)

-Infertility

-Enlarged ovaries with numerous immature follicles that never reach maturation / ovulation. 

-Elevated levels of testosterone and LH

-High levels of AMH  (see Get to Know Your Fertility Bloodwork for more on normal range lab results)

How are you diagnosed with PCOS? 

In 2003, a group of doctors got together to try to define the trademark symptoms of PCOS in order to better identify its patient population. They came up with the following diagnostic criteria.  To be diagnosed, you must show 2 out of the 3 following symptoms: 

  • Ovulatory dysfunction causing menstrual irregularity

  • Clinical or biochemical evidence of hyperandrogenism.

  • This is an overproduction of the male sex hormones (androgens, specifically testosterone, and can result in things like hair growth on the face and acne). 

  • > 10 follicles per ovary (detected by pelvic ultrasonography), usually occurring in the periphery and resembling a string of pearls

Premature puberty and/or failure to establish regular periods in young girls seem to be early markers of future PCOS. 

Where does PCOS come from?

While the etiology is still unknown, studies strongly suggest that there is a genetic component (aka you are more likely to have PCOS if someone in your family has had it). Environment (diet and lifestyle) are also known to trigger an underlying genetic predisposition to PCOS.   Exposure to testosterone in utero (while developing in the womb) can affect your predisposition to PCOS as well. 

The Two Main Mechanisms Behind PCOS: 

1. Defect in the regulation of gonadotropin secretion

2. Hyperinsulinemia (excess levels of insulin circulating in the blood relative to the level of sugars)

Defect in Gonadotrophin Secretion: Lutienizing Hormone (LH)

Research suggests that woman with PCOS present with a problem in the feedback loop (aka the communication) between the brain and the ovaries.

In normal menstrual cycles, follicles in the ovaries will continue to grow and release an egg at maturation. A surge in LH is what triggers ovulation and releases an egg. (see Know Thy Cycle Part II: The Chemicals Involved).

With PCOS however, for some reason egg follicles stall half way through development. These premature follicles produce estrogen which tell the brain to send down LH in readiness for ovulation. However, since none of the follicles are mature enough to ovulate, the feedback loop is stuck sending a stream of LH throughout the cycle. LH levels remain steadily high, instead of surging. And if there is no obvious surge in LH, ovulation is not triggered, or triggers late, and periods are irregular. 

Hyperinsulinemia:

Hyperinsulinemia is defined as too much insulin in the blood. Now how does one get to the point where it's body is producing too much insulin? 

Insulin is made by the pancreas. It takes sugar out of the blood and puts it into the cells and muscles (think: insul-IN...to the muscles). If someone has a diet heavily biased towards carbs and sugars cells become resistant to insulin stimulation and require higher and higher amounts of insulin to trigger sugar uptake out of the blood and into the cells .

Dr. Mark Perloe uses a great analogy to explain insulin resistance.   Picture a crowded metro train in Japan, with the occasional subway worker patrolling the platform. The train represents the muscles of the body and the passengers are sugars in the blood (glucose). During normal hours passengers get onto the train with no problem and ride to the places they need to go.   Similarly, in normal uptake of blood sugar, glucose enters into the cells and is carried off to be used for cell metabolism. 

But then rush hour comes along and the trains are already packed full of passengers. The people on the platform try to get in but can't fit into the crowded train. In Japan, metro stations hire "passenger arrangement staff" to push people into the crowded subway train. The more passengers on the platform, the more pushers they need to shove people into the train. 

The pushers represent the insulin of the body. If muscles are already full of glucose, and sugars remain in the bloodstream,  the body sends more and more insulin to try to push the excess in. The result? Too much insulin in your blood: Hyperinsulinemia.

Why does Hyperinsulinemia matter when it come to PCOS? 

Its interesting to note that both obese and non-obese women with PCOS have shown to be more insulin resistant and hyperinsulinaemic than age and weight matched normal women. 

And guess what? The ovaries possess insulin receptors!  In vitro studies demonstrate that insulin can directly stimulate androgen production by the ovaries.

And so it goes: a diet of carbs and sugars packs your cells full of sugar. The body sends more insulin into the bloodstream to push blood sugar into the already overly packed cells. Your blood becomes full of insulin. Excess insulin attaches to receptors on your ovaries and stimulates an increase in testosterone production. Even a slight increase in testosterone can suppress normal menstruation and ovulation and may stimulate secondary male sex characteristics including symptoms like hair growth on your chin, lower abdomen, and chest, as well as acne, and temporal balding. 

So what can you do to increase your fertility if you are diagnoses with PCOS? 

Because the underlying pathophysiology of PCOS is not fully understood, Western Medical treatment is currently directed at symptoms rather than targeting a specific etiologic pathway. Drugs like Metformin to control insulin, and Clomiphene to stimulate ovulation are often used, but not with out side effects. 

How can you regulate insulin and hormones naturally? 

It doesn't make much sense to try to chase symptoms without targeting the root of the problem, right? 

So of course I'm going to say: see your acupuncturist to treat the root. (see But Seriously, How Does Acupuncture Work?) We treat PCOS by accessing your individual pattern and treating underlying excesses and deficiencies with herbs. Schedule an appointment with your local acupuncturist as soon as possible to get your body's hormones regulated and prepped for baby making. Acupuncture will also help with weight loss for those struggling with insulin resistance. 

The 2nd way to approach PCOS is to adjust your diet. A large percentage of women, overweight or not, will benefit adjusting their food plan to include whole foods like cooked veggies, lean meats, and nuts. Stay away from the middle isles in the grocery store which are full of processed foods that spike insulin levels. .  Start thinking of your food as medicine. What foods will nurture your body? What foods will slow it down? Think of these questions with each meal decision in front of you. 

Look out for my next post where I review the best PCOS food plans out there on the internet. 

The 3rd action item is to start building muscle! Think of the train analogy- the more trains your have, the more room for passengers. If you build more muscle, there is more tissue for your body to clear more glucose from the bloodstream, and thus requires less insulin from the pancreas. Exercises like pilates or yoga are great ways to build lean muscle without over-exercising and burning out your adrenal glands. 

And finally:

If you've been diagnosed with PCOS don't get discouraged. Stay proactive in your understanding of the syndrome, make an effort to change your lifestyle around whole foods and building muscle, and lean on an acupuncturist or medical practitioner to guide your through the next steps in shaping your PCOS fertility story.   Check back soon for posts on PCOS meal plans, PCOS support groups and more recommendations from the Eastern and Western medical communities. 

References: 

Lyttleton, Jane. Treatment of Infertility with Chinese Medicine. Edinburgh: Churchill Livingstone/Elsevier, 2013. Print

Maciocia, Giovanni. Obstetrics and Gynecology in Chinese Medicine. Edinburgh: Churchill Livingstone, 2011. Print.

Nestler, John E. "Insulin Regulation of Human Ovarian Androgens." N.p., n.d. Web.

https://oup.silverchair-cdn.com/oup/backfile/Content_public/Journal/humrep/12/suppl_1/10.1093/humrep/12.suppl_1.53/2/12-suppl_1-53.pdf?Expires=1499901085&Signature=f~1pWQBZz8P89A0P1MyBraTdYMYlN5CHO4LVfZF0RUkeldrTVC7l~Oo2y-DlZ-1l9lPfPzaOCU0GmmjRbwzFwiJITFt8m6zZLf6qAWFf9i5apdhphkxV8P3xpsmjJ9oqbs0xpt0q8a9OQE4sN~FP866zWF91Aq-MwvGQ5bMQQJKDqeSWqOkZJ~bvXIPLNMiCutE5Nqy0AGcmg7jjb2qYkLCZ2L0scEnnyKjInYfYHR~9YK4YleyGSDJmEkRBu0gLpRrpWcHkbR4Cky62-c3TRtmUcnoOy3wgzOtHUvKKgXCXczjUeIIqMF~LuHh4qv2aY42YRTdaKFkzXnPazzOzRw__&Key-Pair-Id=APKAIUCZBIA4LVPAVW3Q

"PCOS (Polycystic Ovary Syndrome): General Information." Center for Young Womens Health. N.p., n.d. Web. 11 July. Posted under Health Guides. Updated 25 May 2016.+Related Content.2017. http://youngwomenshealth.org/2014/02/25/polycystic-ovary-syndrome/

"Polycystic Ovary Syndrome (PCOS) - Gynecology and Obstetrics." Merck Manuals Professional Edition. N.p., n.d. Web. 05 July 2017. http://www.merckmanuals.com/professional/gynecology-and-obstetrics/menstrual-abnormalities/polycystic-ovary-syndrome-pcos

Weschler, Toni, Kate Sweeney, and Christine Shafner. Taking Charge of Your Fertility: The Definitive Guide to Natural Birth Control, Pregnancy Achievement, and Reproductive Health. New York: HarperCollins, 2006. Print

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