Polycystic Ovary Syndrome (PCOS) and Insulin Resistance

Polycystic ovary syndrome (PCOS) is one of the most common female endocrine disorders. PCOS is a hormone disorder that affects an estimated 6-10% of all women, some of whom may not even know they have it.

Most health professionals now accept the underlying cause of PCOS is insulin resistancesyndrome, a condition that leads to poor blood sugar control and weight gain.

Insulin resistance syndrome can occur in both overweight and non-overweight women with PCOS. Other well acknowledged triggers include stress, estrogen dominance and elevated testosterone levels.

PCOS is thought to be one of the leading causes of female subfertility and the most frequent endocrine problem in women of reproductive age.

PCOS is characterized by the accumulation of what appears to be numerous fluid-filled cysts on the ovaries. These develop over time as the ova (eggs) fail to mature, then are released during the menstrual cycle. This causes multiple immature ova to be visible on an ultrasound, which are mistakenly called cysts.

In each menstrual cycle, follicles grow on the ovaries. Within those follicles eggs develop, one of which will reach maturity faster than the others and be released into the fallopian tubes. This is known as ovulation. The remaining follicles (sometimes hundreds) will degenerate.

In the case of polycystic ovaries, however, the ovaries are much larger than normal, and there are a series of undeveloped follicles that appear in clumps, rather like a bunch of grapes. Polycystic ovaries are not particularly troublesome and in many cases they will not even affect your fertility. Where the problem starts, however, is when the cysts cause a hormonal imbalance, which result in other symptoms.

Normally the ovaries release an egg each month in response to hormone changes - the fluctuation of oestrogen and progesterone. This response is stimulated by hormones released from your pituitary gland, luteinizing hormone (LH) and follicle stimulating hormone (FSH). In PCOS, there is an excessive level of androgens such as testosterone and androstenedione, which affects the level of oestrogen necessary for ovulation.

In summary, PCOS is caused by an imbalance of hormones as well as possible insulin resistance. There can be many unripe cysts and the follicles fail to mature properly. Anovulation (no ovulation) is a common feature, which is a cause of infertility.

More About PCOS
The principal features of PCOS are anovulation, resulting in irregular menstruation, amenorrhea, ovulation-related infertility, and polycystic ovaries; excessive amounts or effects of androgenic (masculinizing) hormones, resulting in acne and hirsutism; and insulin resistance, often associated with obesity, Type 2 diabetes, and high cholesterol levels. The symptoms and severity of the syndrome vary greatly among affected women.

Common symptoms of PCOS include the following:

• Menstrual disorders: PCOS mostly produces oligomenorrhea (few menstrual periods) or amenorrhea (no menstrual periods), but other types of menstrual disorders may also occur.
• Infertility: This generally results directly from chronic anovulation (lack of ovulation).
• High levels of masculinizing hormones: The most common signs are acne and hirsutism (male pattern of hair growth), but it may produce hypermenorrhea (very frequent menstrual periods) or other symptoms.[9][7] Approximately three-quarters of patients with PCOS (by the diagnostic criteria of NIH/NICHD 1990) have evidence of hyperandrogenemia.
• Metabolic syndrome: This appears as a tendency towards central obesity and other symptoms associated with insulin resistance.[7] Serum insulin, insulin resistance and homocysteine levels are higher in women with PCOS.

Note: Not all women with PCOS have polycystic ovaries (PCO), nor do all women with ovarian cysts have PCOS; although a pelvic ultrasound is a major diagnostic tool, it is not the only one. The diagnosis is straightforward using the Rotterdam criteria, even when the syndrome is associated with a wide range of symptoms.

Pathogenesis
Polycystic ovaries develop when the ovaries are stimulated to produce excessive amounts of male hormones (androgens), particularly testosterone, by either one or a combination of the following (almost certainly combined with genetic susceptibility):
-- the release of excessive luteinizing hormone (LH) by the anterior pituitary gland
-- through high levels of insulin in the blood (hyperinsulinaemia) in women whose ovaries are sensitive to this stimulus

Alternatively or as well, reduced levels of sex-hormone binding globulin can result in increased free androgens.

The syndrome acquired its most widely used name due to the common sign on ultrasound examination of multiple (poly) ovarian cysts. These "cysts" are actually immature follicles, not cysts ("polyfollicular ovary syndrome" would have been a more accurate name). The follicles have developed from primordial follicles, but the development has stopped ("arrested") at an early antral stage due to the disturbed ovarian function. The follicles may be oriented along the ovarian periphery, appearing as a 'string of pearls' on ultrasound examination.

A majority of patients with PCOS have insulin resistance and/or are obese. Their elevated insulin levels contribute to or cause the abnormalities seen in the hypothalamic-pituitary-ovarian axis that lead to PCOS. Hyperinsulinemia increases GnRH pulse frequency, LH over FSH dominance, increased ovarian androgen production,[8] decreased follicular maturation, and decreased SHBG binding; all these steps contribute to the development of PCOS. Insulin resistance is a common finding among patients of normal weight as well as overweight patients.

In many cases PCOS is characterised by a complex positive feedback loop of insulin resistance and hyperandrogenism. In most cases it can not be determined which (if any) of those two should be regarded causative. Experimental treatment with either antiandrogens or insulin sensitizing agents improves both hyperandrogenism and insulin resistance.

Adipose tissue possesses aromatase, an enzyme that converts androstenedione to estrone and testosterone to estradiol. The excess of adipose tissue in obese patients creates the paradox of having both excess androgens (which are responsible for hirsutism and virilization) and estrogens (which inhibits FSH via negative feedback).

PCOS may be associated with chronic inflammation, with several investigators correlating inflammatory mediators with anovulation and other PCOS symptoms.

It has previously been suggested that the excessive androgen production in PCOS could be caused by a decreased serum level of IGFBP-1, in turn increasing the level of free IGF-I which stimulates ovarian androgen production, but recent data concludes this mechanism to be unlikely.

PCOS has also been associated with a specific FMR1 sub-genotype. The research suggests that women who have heterozygous-normal/low FMR1 have polycystic-like symptoms of excessive follicle-activity and hyperactive ovarian function.

Treatment
Medical treatment of PCOS is tailored to the patient's goals. Broadly, these may be considered under four categories:
-- Lowering of insulin levels
-- Restoration of fertility
-- Treatment of hirsutism or acne
-- Restoration of regular menstruation, and prevention of endometrial hyperplasia and endometrial cancer

In each of these areas, there is considerable debate as to the optimal treatment. One of the major reasons for this is the lack of large scale clinical trials comparing different treatments. Smaller trials tend to be less reliable and hence may produce conflicting results.

General interventions that help to reduce weight or insulin resistance can be beneficial for all these aims, because they address what is believed to be the underlying cause.

Alternative Treatments
Given the pathology of PCOS, the optimum alternative treatment should include a comprehensive wellness program that addresses the insulin resistance, weight gain, hormonal imbalance, and stress.  

A plant-based diet (such as the Death to Diabetes Super Meal Diet) would help to reduce the insulin resistance, increase weight loss, and improve overall hormonal balance.

Along with diet, exercise must be performed to invigorate the body and also to lose weight. Weight loss helps reduce the severity of insulin resistance and while it is more difficult for those with PCOS to lose weight regular light exercise can have an amazing effect when combined with a plant-based anti-inflammatory diet.

Dealing with stress is also important especially since stress weakens your immune system and increases your levels of cortisol (the stress hormone).

Note: A wellness program such as the Death to Diabetes Wellness Program addresses all of these issues, plus more.

Other Alternative Treatment Strategies
Other areas of natural treatment practice you may wish to consider include the following:

Kinesiology: Kinesiologists use muscle testing to identify imbalances in the body and discover what the body needs for healing. They may utilize various other complementary therapies when working with a patient including nutrition, acupressure, affirmations and flower remedies. There are many branches of kinesiology and you should seek out a practitioner who has followed a thorough course (I consult with a systematic kinesiologist) in their field and is accredited by a respected school or organization.

Herbalism: As the name suggests, Herbalists use herbs and medicinal plants to treat a patient, seeking to treat the underlying cause of any disease or illness (in this case PCOS) with an aim to also prevent further disease and help the body to heal itself. Herbal medicine is safe and effective when prescribed by a fully qualified herbal practitioner (do not self-medicate as many herbs can have strong and unexpected effects, especially in combination).

Homeopathy: This holistic system is based on the theory of treating "like with like". i.e. using highly diluted natural substances that if given in stronger doses to a healthy person would produce the symptoms you are experiencing. It is a very subtle and gentle therapy and probably the only one that cannot be practiced in conjunction with any prescription drugs. Again, choose your practitioner wisely.

Note: If you have an autoimmune disease, PCOS, or thyroid issues, get the How to Treat Autoimmune Diseases, PCOS & Thyroid Issues Naturally ebook. 

References

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