Dr. Anjan Nibber sheds some light on a rare disease, garnering some publicity, and offers a lesson about brain health in this week’s blog… In 2011 the world mourned the death of Knut the polar bear, who had stolen the hearts of everyone who had visited the Berlin Zoo or who had followed his high profile career of modeling alongside celebrities like Leonardo DiCaprio. In 2012, Sussanah Calahan released her memoir Brain on Fire: My Month of Madness, which chronicled her struggle with NMDA receptor mediated-encephalitis. It was soon discovered that the same disease that Sussanah Calahan wrote about was
Polycystic ovary syndrome (PCOS) is considered one of the leading endocrine disorders affecting up to 10% of all women of reproductive age.1 It is a complex disorder stemming from inappropriate hypothalamic-pituitary- ovarian interaction (see the article titled “An introduction to the HPG Axis”), thought to be one of the leading causes of infertility. Why and how PCOS develops is not yet understood, although accumulating evidence suggests that it may be mostly genetic.2,3
Diagnosis, Symptoms and Risks
A PCOS diagnosis is based on menstrual irregularity, excessive
The principal symptoms of PCOS emerge
late in puberty or shortly after, stemming from two main causes: 1) a lack of
ovulation, which may or may
not result in irregular menstruation, and 2) excessive amounts (or due to the effects) of androgenic hormones, which cause hirsutism (excessive facial and body hair).2,3 It is not uncommon for women with PCOS to encounter other difficulties such as infertility, high risk of miscarriage, accumulation of visceral fat, obesity, various cardiovascular diseases such as diabetes, dyslipidemia, hypertension, and Metabolic Syndrome later in life.3-8 The severity of symptoms, especially hirsutism and obesity, can lead to feelings of low self-esteem, anxiety, depression and low quality of life.9
Currently, four categories of PCOS have been identified.14 The first is characterized by the presence of menstrual irregularities, polycystic ovaries and hyperandrogenemia (excessive masculinizing hormones),
esistance than those without PCOS, while only obese/overweight women in the fourth category share the same risk. Overweight women in the first category, however, have the highest risk for insulin resistance. Serum androgen levels are highest in both lean and overweight/obese women in PCOS categories one to three compared to those in the fourth.14
Early diagnosis and preventative measures are of the utmost importance in promoting long-term health, decreasing the risk of developing other secondary illnesses, and even preventing the development of cardiovascular diseases.15 However, due to the individualized nature of PCOS, management must be tailored to target the displayed symptoms and to prevent the risk factors that you may have a predisposition for. It is also important to monitor progress and the development of new symptoms, and change the management routine accordingly.
Dietary and Lifestyle Changes
First line therapy for women with PCOS, and the only therapy incurring lifelong benefits with minimal side
Lifestyle changes can also have an impact on PCOS symptoms. It was shown that 1 hour of exercise (aerobic, resistance, or endurance) three times per week for 12-16 weeks, significantly improved insulin resistance, ovarian hormones, and reproductive function.23-26 It was also shown that the addition of aerobic or combined aerobic-resistance exercise to a calorie restricted diet significantly improved body composition in overweight and obese women with PCOS compared to those on a low calorie diet only.27
Even if healthy dietary and lifestyle options alone are not enough, a healthy lifestyle can significantly improve the success rate of
Supplementation Some women with PCOS may not achieve adequate symptom relief from dietary and lifestyle changes alone, and therefore they may seek natural interventions to boost the results of healthy lifestyle modifications.
Chromium: To reduce the risk of developing type 2 diabetes, it is crucial to reduce insulin resistance. Chromium is a well-known element that has been found to reduce high insulin at doses of 200-1000 mcg/day, and the picolinate salt was found to be the most bioavailable chromium salt.28 Interestingly, circulating serum chromium has been found to be low in women with PCOS, and was directly correlated with fasting insulin levels.29 The same study also found that women with PCOS had lower serum manganese and magnesium, but higher serum calcium, zinc and copper than women without PCOS, and the differences were more pronounced in women with PCOS and insulin resistance.29
Cinnamon & Gymnema: Cinnamon was also
Folate: Folate (L-5- methyltetrahydrofolate, L-5-MTHF) is a crucial B vitamin especially for any woman looking to conceive, as it is a simple way to prevent neural tube defects in developing fetuses. However, it can also help reduce homocysteine, which is associated with recurrent pregnancy loss and an increased risk of cardiovascular disorders including dyslipidemia and blood clot formation.29,38 Folate intake was shown to significantly reduce homocysteine levels in women with PCOS 39 at doses between 400-1000 mcg. However many women can’t even metabolize regular supplemental folate due to a common genetic mutation that makes them unable to convert the folate to its active form, L-5-MTHF. 40 This can be overcome by directly supplementing with the bioactive folate form, L-5- MTHF.
Inositol: The development of insulin resistance may be linked to a deficiency in inositol, which is a messenger needed for insulin signaling.41 The human body contains two forms of inositol, myo-inositol (the most abundant form), and D-chiro-inositol; the ratios of each are different in each organ depending on that organ’s needs. Ovaries require a high level of myo- inositol – in fact, a link between high concentrations of myo-inositol and quality, mature oocytes (egg cells) has been established.42 It is therefore not surprising that supplementing with myo-inositol (4g/day) during in vitro fertilization treatments have been shown to significantly improve oocyte quality, improving the chance of developing a healthy embryo by improving insulin sensitivity.43-45 However, evidence on D-chiro-inositol supplementation is controversial, with a recent study even showing worsening of oocyte quality and reduced ovarian response to fertility treatments.46
Melatonin: Melatonin supplementation was also found to improve oocyte quality and pregnancy rates in women undergoing in vitro fertilization.47 Melatonin reduces oxidative stress within the follicle. Oxidative stress increases significantly during the ovulatory process and is suspected to be a cause of poor oocyte quality.48 The addition of 3mg/day of melatonin to myo-inositol and folic acid supplementation significantly improves oocyte quality and pregnancy outcome in women with poor oocyte quality.49
Omega-3s: Supplementing with omega-3 fatty acids was shown to significantly reduce liver fat content, thereby preventing or reducing fatty liver disease, in addition to improving serum adiponectin levels (a protein involved in regulating glucose levels as well as fatty acid breakdown), insulin resistance and cholesterol in women with PCOS49,50 while another group showed that greater plasma polyunsaturated fatty acids, particularly long chain omega-3s, improve the androgenic profile in women with PCOS.51
Anti-androgenic herbs: These can be used to lower androgen levels in women with PCOS, helping to reduce hirsutism and balding. Spearmint herbal tea was shown to have significant anti- androgen effects in polycystic women; however, because hirsutism and balding require more time to resolve in response to lowering androgen levels, the short duration of the trials did not permit them to decrease significantly. However, it is expected that longer term intake of spearmint tea would produce significant results.52,53 While other known anti-androgen herbs like saw palmetto and standardized pollen extracts have not been studied in women with PCOS, their well- known anti-androgenic properties are expected to reduce symptoms of high androgen levels in women with PCOS. Anti-androgenic supplementation or medication must not be taken during pregnancy or when trying to conceive however, as they have the potential of feminizing male fetuses.
Soy isoflavones: There are many options available to manage high cholesterol levels and improve the body’s lipid profile. Soy isoflavones have been studied in women with PCOS, and an intake of 36 mg/day of genistein for 6 months in dyslipidemic women improved their lipid profiles.54
Somewomenmayoptforprescription medication, and in severe cases, surgical intervention may be warranted. It must be noted however that lifestyle changes, including healthy diet and
For hirsutism, there are many available options. Tweezing, waxing, sugaring and shaving are the cheapest methods; however, these only provide temporary relief. More permanent relief can be provided with electrolysis or laser hair removal. Permanent hair reduction with either laser or electrolysis may take up to 2 years to significantly reduce hair growth.
Being diagnosed with PCOS may seem
daunting and overwhelming, and although
it is a lifelong condition with no cure, it is highly manageable.
Key to“Should I Ask My Doctor if I Have PCOS?”
Award 1 point each if you: Q1: Answered c, d or e Q2: Circled 3 or more sites Q3: Answered“yes”
For Q4, if you answered“yes”, then subtract 1 point, if you answered“no” then don’t change your points.
If you get ≥2 points, then you may have PCOS and should speak to your doctor.
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