Overview: Polycystic Ovarian Syndrome

• Polycystic ovarian syndrome (PCOS) is the most common female endocrine disorder, affecting 10% of women of reproductive age, yet it is frequently overlooked.

• PCOS affects young women with oligo-ovulation (which leads to oligomenorrhea in more than 75% of affected patients), infertility, acne, and hirsutism. It also has notable metabolic sequelae, including an elevated risk of diabetes and cardiovascular disease, and attention to these factors is important.

• The heterogeneous nature of the condition and the diversity of presentations led to a symptom-based approach to treatment, because PCOS manifests differently, depending on many interacting factors including environmental exposures, genetics, and lifestyle.

• This chapter discusses the pathophysiology and integrative approach to treatment of women with PCOS.

Importants Points to Consider

• A thorough clinical assessment is critical both to confirm the diagnosis and to identify risk factors for long-term health maintenance. This information helps the clinician prioritize integrative approaches when creating a management plan by elucidating the primary metabolic targets. The plan should take into equal consideration each woman's unique concerns such as weight management, acne, hair loss, or infertility.

• More studies need to be conducted on soy consumption in polycystic ovarian syndrome (PCOS). Women with PCOS who struggle with infertility, consume few calories, or eat a poor diet may want to avoid or limit soy products. Otherwise, a moderate to low intake of soy (once a day or several times a week) can be part of a healthy diet for women with PCOS.

• Although oral contraceptive (OCP) use helps many women overcome the troublesome symptoms of polycystic ovarian syndrome (PCOS), these drugs have been associated with higher risk of cardiovascular disease in the general population. The risk of cardiovascular disease is associated with increased age, smoking, and hypertension. Additional concerns include a negative impact on inflammatory markers and diabetes risk. Studies are needed in the PCOS population to assess the long-term benefit-to-risk ratio of using OCPs. For now, increased awareness and attention to regular follow-up of metabolic and cardiovascular markers are critical in any woman taking OCPs.

Prevention Prescription

• Maintain appropriate weight and a regular aerobic exercise routine.

• Avoid excessive amounts of saturated fat such as those found in red meat, fried foods, and dairy.

• Replace vegetable oils with olive or canola oil for cooking.

• Consume omega-3–rich fats found in cold-water fish, nuts, greens, and ground flaxseed.

• Encourage soy-based foods such as soy milk, edamame, tempeh, miso, soy nuts, and non-genetically modified tofu. Try to eat 1 to 2 oz a day.

• Avoid dietary supplements or environmental exposures that may increase circulating hormone levels such as pesticides, herbicides, and bovine growth hormone–rich dairy products.

• Avoid supplements or drugs that include dehydroepiandrosterone, androstenedione, testosterone, and human growth hormone.

Therapeutic Review

Lifestyle approaches are first-line recommendations for PCOS, both in conventional and integrative medicine approaches. Many women with PCOS do well with attention to diet, exercise, supplements, and acupuncture. Some women need medications to achieve needed improvements when metabolic derangements are greater.

Lifestyle

• Remove exacerbating factors. Minimize exposure to hormone-disrupting chemicals.

Nutrition

• Promote weight loss to achieve an ideal body weight. Start with achievable goals and provide adequate support.

• Eat 1 to 2 servings of soy-rich foods daily. Each 1-oz serving (approximately the size of the palm of the hand) provides approximately 25 mg.

• Encourage a low-carbohydrate diet that takes into account the glycemic index of foods.

• Encourage foods rich in omega-3 fatty acids (e.g., salmon, nuts, or ground flaxseeds).

Physical Activity

• Recommend moderate exertion 30 to 60 minutes daily.

Supplements

• Vitamin D: 2000 units daily (dose based on serum 25-OH vitamin D level)

• Chromium picolinate: 1000 mcg daily

• D-chiro-inositol/pinitol: 600 mg once or twice per day

Botanicals

• Cinnamomum cassia: ¼ to 1 teaspoon

• Licorice root in conjunction with spironolactone for amelioration of side effects and complementary action

• Chaste tree berry (Vitex): 60 drops of tincture or 175 mg of extract, standardized to 0.6% agnusides

Complementary Therapies

• Acupuncture may reduce sympathetic nervous system tone and improve menstruation. It has additional benefits for stress reduction and mood.

• Mind-body therapies can help women cope with stress, depression, and anxiety related to PCOS.

Pharmaceuticals

• Insulin sensitizers include metformin, at 500 to 1000 mg twice daily.

• If the patient is unable to achieve satisfactory weight loss, consider support with orlistat.

• Medications such as clomiphene may be prescribed in consultation with a reproductive endocrinologist for ovulation induction.

• Antiestrogens for hirsutism include spironolactone, at 50 to 200 mg/day, or flutamide, at 250 mg two to three times a day.

• Oral contraceptive pills are prescribed for amenorrhea, hyperandrogenism, and uterine protection.

Surgical Therapy

• If the patient has morbid obesity with significant comorbidities despite the foregoing measures, consider referral for bariatric surgery.

• Ovarian surgery may be indicated for infertility.

Key Web Sources

• American Association of Clinical Endocrinologists: www.aace. com.

• Womenshealth.gov: www.womenshealth.gov/faq/polycystic-ovary- syndrome.cfm.

• American Society for Reproductive Medicine: www.asrm.org.