Podcast and update on Polycystic Ovarian Syndrome

I had Dr. Shannon Hirst on my podcast (iTunes or Android) and the episode launched this week. She gave some great insights on Polycystic Ovarian Syndrome. I encourage you to listen to Dr. Hirst on the topic and if you are in the Seattle area she is an excellent clinician who has a knack for treating tricky Women's hormonal issues.

In the episode , Dr. Hirst shares some core concepts on how to go about managing PCOS which is a metabolic hormonal issue leading to infertility, weight gain, irregular menstruation, acne, and male pattern hair loss (more on this below). She also shares some of the deep challenges that present with PCOS.

I think this is a great opportunity to review PCOS with you all.

My patients that deal with PCOS are some of the most diligent , motivated, and health-oriented patients there are. The amount of work they have to put into there health is much more then the person without PCOS. The effort required and frustration and disappointment PCOS patients go through is palpable.

PCOS presents with a collection of symptoms and and is confirmed by blood work and sometimes imaging. It often is not diagnosed because the criteria are often not firmly met.

The symptoms include some or all of the following

• Amenorrhea (or missed menstrual cycles)

• Oligomenorrhea (inability to ovulate)

• Acne

• Hirsutism (hair growth on face or abdomen; can be common in middle-eastern and s.e. Asian ancestry)

• Female-pattern baldness

• Mood disorders

• Obesity

Lab work is usually down including:

• Human chorionic gonatotropin (hCG) to rule out pregnancy

• Thyroid function tests (TSH and , free T3, free thyroxine, thyroid antibodies, and sometimes rT3) to rule out thyroid disease as a cause of weight gain or menstrual irregularities;

• serum prolactin to rule out hyperprolactinemia as a cause of ovulatory dysfunction.

• In PCOS, hormone testing will often reveal elevated Luteinizing hormone Hormone(LH), elevated DHEA-S, and elevated free testosterone.

• sometimes we often do serum 17-hydroxyprogesterone (17-OHPG) and anti-Müllerian hormone (AMH) to aid in diagnosis as they are often elevated.

Imaging studies are done often to screen for the classic polycystic appearance of the ovaries including transvaginal ultrasound or pelvic CT or MRI)

It is not necessary for all of these tests or images to be positive to receive a diagnosis.

Evidence of two of the following is required

1. Clinical OR laboratory evidence of hyperandrogenism

2. Anovulation (lack of ovulation)

3. Ultrasound evidence of polycystic ovaries. (often not present)

If diagnosed with PCOS additional tests should be done because having PCOS puts you at risk for depression, anxiety, diabetes, and cholesterol issues. These test include:

1. Lipid Profile

2. Hemoglobin A1c

3. Screening for Depression using PHQ-9

4. Screening for General Anxiety using GAD-7 questionnaire

The cause of PCOS is often linked to imbalance caused by excessive androgens (see diagram).

1. Increased Luteinizing Hormone ( LH) production by the anterior pituitary gland increases Theca lutein cells production which are located in follicular ovarian cysts. These theca cells overproduce DHEA and Testosterone . The ovarian theca cells (the site androgen biosynthesis), are increased in number in polycystic ovaries.

2. The increased number and steroidogenic capacity of theca cells in PCOS leads to excessive production of androstenedione, which is metabolized to testosterone and 5D-androstane-3,17-dione rather than estrogen by the granulosa cells.

3. Insulin Resistance inhibits Sex Hormone Binding Globulin production in the liver so you have increased free testosterone in circulation Insulin resistance in fat cells (adipocytes) causes increased testosterone production in ovaries.

4. Insulin resistance and high androgens leads to less effective ovulation. It is postulated that ovulation issues in PCOS is secondary by abnormal interaction of insulin and luteinizing hormone (LH) on granulosa cells. Granulosa convert androgens (coming from the thecal cells) to estradiol by aromatase during the follicular phase of the menstrual cycle. This is a key step in ovulation.

Treatment for PCOS usually involves approaches to dietary wise to reduce insulin resistance, restore ovulation, and also to help with anxiety and depression. Conventionally PCOS patients are often put on birth control modalities to regulate hormones and metformin to control insulin resistance.

As a Naturopathic Physician have a whole host of researched nutrients and herbal medicines that help with PCOS such as D-chiro Inositol , N-acetyl Cysteine, Peony root flower, and Glycyrrhiza glabra . Another stellar treatment is Berberine which helps with glucose stabilization and reducing insulin resistance. I am also fortunate to work with a talented acupuncturist Kaira Jorgensen, EAMP, LaC who has a practice specializing in fertility and she helps many women with PCOS. Click on the links to see studies in PCOS

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sources:

Guiltinan, J. (2016, 07). Tap Integrative PCOS. Retrieved from Tap Integrative: www.tapintegrative.com

Magoffin, D. (2007). Ovarian Steroidogenic Abnormalities. In e. a. Azziz, Contemporary Endocrinology: Androgen Excess Disorders in Women: (pp. 203-210). Totwana, NJ: Humana Press.