Stop Polycystic Ovary Syndrome Naturally

The Natural Pcos Diet

The Natural Pcos Diet, By Jenny Blondel, A Leading Australian Naturopath In Response To Thousands Of Requests For Professional Information To Help Women Suffering From Pcos. Real Solutions To Naturally Overcome PCOS. Naturally balance your hormones Increase your chances of conceiving Help you lose weight and feel good Curb your cravings for sugary foods Turn your fatigue around Achieve clearer, glowing skin See improvements in your mood. Do You Feel PCOS Is. Ruling Your Life? At Last! The Natural PCOS Diet. A Naturopath’s Easy Step-by-Step Guide to Overcoming PCOS Is. Now Available! Continue reading...

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Diagnosis and Management of Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is a heterogeneous condition associated with irregular menstrual cycles and androgen excess. Additional terminologies used to describe the syndrome include Stein-Leventhal syndrome, named for the authors of the first published description in 1935, or sclerocystic ovarian disease. An international consensus conference has proposed that the syndrome can be diagnosed if at least two of the following features are present irregular or absent ovulation, elevated androgens or clinical androgen excess, and polycystic ovaries on ultrasound (Fig. 5.1). The finding of polycystic ovaries on ultrasound is neither solely diagnostic nor necessary for diagnosis of PCOS. Additionally, the syndrome can only be diagnosed after exclusion of other medical conditions. Differential diagnosis of PCOS includes nonclassic adrenal hyperplasia due to 21-hydroxylase deficiency, Cushing's syndrome, hyperprolactinemia, hypothyroidism, acromegaly or virilization due to an adrenal or...

Insulin Resistance associated but not required for diagnosis

Typical is onset of menstrual irregularity at a later age. It is now recognized however that the condition of PCOS can exist in women with regular menses. The most distinctive feature is that of clinical androgen excess. Hirsutism is usually present and can range from mild to severe. Usually hair growth is present on the face and chin as well as the lower abdomen. It is also not uncommon to see frontal hair loss and thinning of scalp hair. Acanthosis nigricans, a dark thickening of the skin, is often present. It can be found at the base of the neck, the axilla and under the breast. Acne is also often present from adolescence but by itself may not be a distinguishing feature of PCOS.

Metabolic Complications

Although PCOS often presents in the early reproductive years, it is now recognized that the consequences of PCOS extend beyond the reproductive axis and the reproductive years. Women with PCOS appear to be at substantial risk of developing diabetes and cardiovascular disease. Several studies indicate that the risk of metabolic syndrome in PCOS is approximately 50 in young adulthood. Metabolic syndrome is a constellation of metabolic risk factors that increase the risk of cardiovascular events 2-fold. For women, these include increased abdominal waist circumference ( 88 cm), elevated triglycerides ( 150 mg dL), reduced HDL ( 130 mm Hg systolic or 85 mm Hg diastolic or drug treatment for hypertension), and elevated fasting glucose ( 100 mg dL). Many women with PCOS develop impaired glucose tolerance or frank diabetes. In studies of obese women with PCOS 30-40 will have previously undiagnosed impaired glucose tolerance and as many as 10 will have frank type 2 diabetes. This increased...

Oral Contraceptives and Progestins

One first line agent that is used for the control of menstrual irregularity is also the predominant treatment for androgen suppression. Use of combination oral contraceptives will significantly reduce circulating free testosterone. Oral contraceptives contain ethinyl estradiol which will suppress LH secretion from the pituitary and decrease LH-driven production of testosterone from the ovary. Additionally, estrogenic compounds increase SHBG production in the liver which will reduce the circulating component of free testosterone. The progestin component of the oral contraceptive will also contribute to LH suppression. The type of progestin varies in different combination oral contraceptives. Progestins can have variable androgenic activity as they are derived from an androgenic base. Drosperinone, an analog of spironolactone with unique anti-androgenic activity, also has progestin activity and is now available in an oral contraceptive. At this time, it has not yet been studied for its...

Lifestyle Modification

Weight reduction, of as little as 3-5 , has been associated with improvements in ovulation rates in PCOS women who are overweight or obese. Although studies are consistent in this regard, no large scale controlled trials are available to assess improvements in pregnancy rates. There are no specific dietary regimens that target PCOS and effective weight reduction has been demonstrated with a wide variety of approaches. over time and should be encouraged. Significant support is needed to encourage women with PCOS who are overweight or obese to consider lifestyle modification as the first line of therapy.

What are the commonly utilized study designs

Prostate Cancer Outcomes Study (PCOS). The PCOS is an National Cancer Institute-initiated study that was launched in 1994 as a longitudinal, community-based study of prostate cancer.45 After patients were diagnosed and entered into the study, patients were asked to recall their pretreatment QOL, and were then studied at 6, 12 and 24 months after treatment, using the SF-36 and validated disease-specific instruments. The study primarily included men treated with RP or XRT, but also included and separately reported men treated with hormonal therapy. The study's strength lies in its large size, longitudinal design and multicenter community-based design, which makes the results more generalizable to the population at large, in contrast to data from single academic medical centers. Its potential con-founders include the low response rate of 62 (with further loss to follow-up over time), and the use of recall bias. The use of recall for pretreatment assessment has been criticized,46 and...

Radical prostatectomy

In the PCOS report on radical prostatectomy,51 the findings at 18 months included incontinence in 8.4 and impotence in 59.9 . Age, nerve sparing and race affected sexual function and, beyond 18 months, 41.9 reported their sexual function was a moderate to large problem. Litwin et al.36 reported a single-institution longitudinal study that included baseline measurements. As with the PCOS, response rates dropped from 90 over time to 65 overall. In the SF-36, 60 reached baseline by 3 months, and 90 by 12 months with a mean 4.5 month recovery. The domains role physical, role emotional and social function showed the greatest improvement. In some domains, as social and emotional, the scores improved from baseline, indicating that patients adjust to their diagnosis once it is treated and time passes. Urinary function improved 21 at 3 months, 56 at 12 months, and 63 at 30 months, with over 80 eventually recovering urinary bother. Sexual function recovered 33 at 1 year and 40 at 2 years, with...

Reproductive Endocrinology Diagnostic Imaging

Hsg Patient Images

Other causes of ambiguous genitalia include gestational hyperandrogenism often related to maternal hyperandrogenism during pregnancy. A genotypic male infant with 5-alpha reductase deficiency can also present initially as a minimally-virilized female infant. Polycystic ovary syndrome (PCOS) is another anovulatory condition that contributes to infertility. An international consensus conference in 2003 created a working definition for PCOS, the Rotterdam criteria. These criteria defined PCOS as the presence of any two of three findings 2. Clinical or biochemical evidence of hyperandrogenism 3. Polycystic ovaries on ultrasound Defined as 12 or more follicles measuring 2-9 mm in each ovary or ovarian volumes of greater than 10 ml. Ovaries from a woman with polycystic ovarian syndrome classically demonstrate an abundance of peripherally situated follicles that create the ring of pearls appearance that typifies this syndrome (Fig. 12.19). However, authors have debated the importance of...

Programmed Superovulation Protocols

Patients with polycystic ovarian syndrome are at particular risk of OHSS when treated with gonadotrophins. The syndrome displays a range of pathologies, depending on the patient's physiology and extent of gonadotrophin treatment, which has been classified as mild, moderate or severe. The majority of OHSS cases fall into the moderate category, and are managed conservatively with careful monitoring. Conception cycles are more likely to result in severe OHSS, and these patients are at risk of a number of serious vascular, renal, hepatic and respiratory complications. They should be admitted to hospital for intensive monitoring and therapy according to the type of potential complication. The most effective means of OHSS treatment is its prediction and prevention, by trying to identify those patients who may be at risk and managing their treatment cycle with careful monitoring and preventive action such as withholding HCG, continuation of GnRh agonist treatment, or avoiding conception by...

Surgical Treatment of Female Infertility

Posterior Cul Sac

Laparoscopic Treatment of Polycystic Ovary Syndrome (PCOS) The first line of treatment for anovulatory women with polycystic ovary syndrome is ovulation induction with ovulation-inducing drugs . This has replaced the outdated surgical treatment with ovarian wedge-resection. A modification of ovarian wedge resection is laparoscopic ovarian drilling (Fig. 14.9). This is performed by creating multiple holes on the surface of the ovary using either electrocautery or laser. As a result, the circulating level of androgen is reduced followed by restoration of pituitary-ovarian axis restoring ovulation. Ovarian drilling is associated with an ovulation rate of 80 and cumulative pregnancy rates at 12, 18, and 24 months of 54-68, 62-73, and 68-82 respectively. 7. Palomba S, Orio Jr F, Falbo A et al. Prospective parallel randomized, double-blind, double-dummy controlled clinical trial comparing clomiphene citrate and metformin as the first-line treatment for ovulation induction in nonobese...

Assisted Reproductive Technology

Insulin resistance, a common finding with polycystic ovarian syndrome (PCOS). Other important features to note are a buffalo hump (Cushing's syndrome) short stature, webbed neck, and shield chest (Turner's syndrome). Finally, a complete pelvic examination is crucial during the initial visit and should include evaluation for Mullerian defects, pelvic or abdominal masses, or tenderness, cervical abnormalities, and nodularity in the cul-de-sac. One should consider performing a cervical culture as well due to the association of chlamydia cervicitis and PID. Routine laboratory tests for infertility include a prolactin level (normal

Insulin Sensitizing Agents

Given the prevalence of insulin resistance seen in PCOS, a number of insulin-sensitizing agents have been studied in the treatment of symptoms. Currently metformin, a biguanide, and pioglitazone and rosiglitazone, thiazolidinediones, are available clinically, and all have been studied in PCOS. The single most common agent for use in PCOS is metformin. Metformin appears to work by reducing hepatic glucose output thereby reducing the demand for insulin. A meta-analysis of thirteen studies of metformin in PCOS concluded that metformin significantly enhanced the rate of ovulation. There was also evidence for improved insulin levels and reduced cholesterol. There is conflicting evidence that metformin's effects are partially mediated through weight reduction. Metformin has been noted in several studies to be associated with weight reduction in the initial phase of treatment, but this is not consistently seen. The effects of metformin on pregnancy loss and gesta-tional diabetes have been...

Consequences of Deficit and Excess Energy Intake

Excess energy intake and positive energy balance are promoted by readily available, energy-dense foods and sedentary lifestyles 11 . The consequences of excess energy and obesity are well described in children 12 . Obesity-related co-morbidities include type-2 diabetes, hyperlipidemia, hypertension, hyperandrogenism in girls, sleep disorders, respiratory difficulties, nonalcoholic fatty liver disease, gallbladder disease, orthopedic problems, and idiopathic intracranial hypertension. Serious psychosocial problems including poor self-esteem and depression also are common. Childhood obesity and its co-morbidities have a significant likelihood of persisting throughout adolescence and into adulthood.

Comparative studies for localized disease

The PCOS trial has published a comparative study of RP versus XRT with 24 months of follow-up.63 SF-36 scores were mostly equivalent, although XRT scored lower for general health. They confirmed other studies demonstrating greater decreases in sexual and urinary function after RP, but more bowel side effect from XRT. Urinary bother mirrored loss of urinary function however, sexual bother differed more by age than by sexual function - older patients reporting less bother. Madalinska etal.65 also performed a longitudinal study in the context of their clinical trial of prostate cancer screening in the Netherlands. They compared RP versus XRT using the SF-36 and UCLA PCI, also comparing patients who were diagnosed from screening clinics versus clinically detected. In contrast to the PCOS and CaPSURE studies that suffered from declining participation over time, the Madalinska study achieved a 91 baseline response rate, which held at 87 at 12 months. Despite theoretic selection biases, the...

Alternative Medicine and Female Infertility

The use of electroacupuncture for ovulation induction in anovulatory women with polycystic ovarian syndrome has been reported. The percentage of ovulatory cycles in all subjects was shown to improve from 15 to 66 up to three months after treatment. Responsive patients had significantly lower body mass index, waist-to-hip circumference ratio, serum testosterone concentration, serum testosterone sex hormone binding globulin ratio, and serum basal insulin level. Therefore, in these selected patients with polycystic ovarian syndrome, acupuncture could be utilized as an alternative or adjunct to conventional pharmacological ovulation induction.

Pathophysiology

No single etiologic factor fully explains all the features of PCOS. Excess androgen production is primarily from the ovary. Increased testosterone production by theca cells of polycystic ovaries has been demonstrated. Increased LH secretion by the pituitary gland is consistently demonstrated. It is not clear if this is a primary defect in the GnRH pulse generator or if this is a secondary phenomena. Increased LH stimulation to the theca cells drives increased androgen production. It is also recognized that women with PCOS, independent of body weight, demonstrate insulin resistance. When carefully studied, most women with PCOS demonstrate hyperinsulinemia. Increased insulin resistance is associated with worsening of the clinical manifestations of PCOS. Insulin acts, along with increased LH secretion, to enhance androgen production from the ovary. Insulin also inhibits hepatic production of sex-hormone binding globulin (SHBG). SHBG is the principle binding protein for testosterone, and...

Impact of Obesity

It is generally recognized that obesity, although not a defining feature of the syndrome, is highly prevalent in PCOS. Most studies in the United States report higher incidences of obesity (upward of 50 ) than those of other countries. There is variable ethnic distribution of obesity in PCOS as well. Obesity is overall highly prevalent in most developed countries, and the rate of obesity is growing rapidly. Insulin resistance, a feature seen independently of body weight in PCOS, is almost universally noted with obesity. As noted previously, insulin resistance, in association with obesity, will worsen the clinical presentation of PCOS. Numerous studies demonstrate worse androgen profile and more severe menstrual disturbances in obese subjects with PCOS compared to their lean counterparts. Response to treatment may also be adversely impacted by obesity.

Key Points

PCOS is a common reproductive disorder in women and is primarily manifest with symptoms of androgen excess and menstrual irregularity. Although identified as a disorder of reproduction, the pathophysiology of PCOS includes insulin resistance, and therefore metabolic abnormalities are common. Treatment of PCOS should address both the endocrine and metabolic aspects of the disease. Attention should be particularly paid to glucose tolerance in overweight and obese women at diagnosis and followed closely. Newer treatments with insulin sensitizing agents have shown promise in the management of PCOS over the long-term, but additional trials are needed.

Suggested Reading

Rotterdam ESHRE ASRM sponsored PCOS Consensus Working Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril 2004 81(1) 19-25. 2. Azziz R, Woods KS, Reyna R et al. The prevalence and features of the polycystic ovary syndrome in an unselected population. J Clin Endocrinol Metab 2004 89(6) 2745-9. 3. Ehrmann DA. Polycystic ovary syndrome. N Engl J Med 2005 352(12) 1223-36. 4. Dunaif A. Finegood DT. Beta-cell dysfunction independent of obesity and glucose intolerance in the polycystic ovary syndrome. J Clin Endocrinol Metab 1996 81(3) 942-7. 5. Lord JM, Flight IH, Norman RJ. Insulin-sensitising drugs (metformin, troglitazone, rosiglitazone, pioglitazone, D-chiro-inositol) for polycystic ovary syndrome. Cochrane Database of Systematic Reviews 2003 (3) CD003053. 6. Legro RS, Kunselman AR, Dodson WC et al. Prevalence and predictors of risk for type 2 diabetes mellitus and impaired glucose tolerance in polycystic...

Radiation therapy

In the PCOS study,52 bowel function decreased at 6 months but improved to baseline by 24 months. Urinary function and bother were essentially not affected by treatment. Sexual function declined over time, such that by 24 months, 43 of all men with pretreatment potency were no longer potent. Bother assessment also declined over time. Other studies have also documented this pattern of sexual function decline.49'53-55 However, reports of impotence after conformal beam radiation therapy have been lower (13-29 )56-58 and etal. reported decreased bowel complications (34 to 10 , P

Metastatic disease

A common dilemma for patients needing androgen deprivation therapy is whether to undergo surgical versus medical castration. While costs, trips to the doctor's office and body image are common features that direct the decision, two recent studies have looked at QOL issues. In the PCOS observational study,74 a large group of patients were identified who were treated with primary androgen ablation for localized, locally advanced and metastatic disease by either LHRH agonist or orchiectomy. This study was non-randomized and several baseline variables were different, making comparisons difficult. Nevertheless, significant declines in sexual function and interest were found with either therapy. Of interest, stage and other prognostic factors did not affect quality of life and satisfaction rates were 90 in each group. Litwin etal.75 performed a longitudinal study using the SF-36 and UCLA PCI. The study is small (47 combined androgen ablation vs. 16 orchiectomy) but achieved an impressive 84...

Ovulation Induction

Polycystic Ovarian Syndrome Etiology

The World Health Organization (WHO) has provided a simplified classification system for disorders of ovulation. This grouping system describes the etiology of anovulation, and the most appropriate treatment for patients with ovulatory dysfunction is determined by their classification. WHO Group I patients have low follicle stimulating hormone (FSH) and luteinizing hormone (LH) levels and low estradiol levels. These patients have hypothalamic-pituitary hypofunction, either congenital or acquired and have a negative progestin challenge test due to low endogenous estradiol levels. WHO group II patients have normal FSH and LH levels, and normal estradiol levels. Most anovulatory patients fall within this category, and 90 of these patients have polycystic ovarian syndrome (PCOS). These patients will have a positive progestin challenge test due to normal endogenous estradiol levels. WHO group III patients have elevated FSH and LH levels. Gonadotropins are elevated (often in the menopausal...

Females Males

Syndrome Albright

Delayed puberty is defined as no signs of puberty by age 14 in boys. In girls, it is defined as either the absence of thelarche by age 13 or menarche by age 15. These are 2.5 standard deviations above the mean for North American children. In boys, delayed puberty signifies that there is a hypogonadal state. In girls, the differential diagnosis is complex and may include a hypogonadal state, anatomic abnormalities, such as absence or obstruction of the outflow tract, and certain disorders with ongoing estrogen production most commonly polycystic ovary syndrome (PCOS). An algorithm is shown in Figure 2.2. Note that the evaluation and diagnostic categories are similar for males with the exception of an obstructed genital tract. Normal I PCOS I If no outflow obstruction is observed in a eugonadal patient and thyroid studies and prolactin are normal, the patient very likely has polycystic ovary syndrome (PCOS) as the cause of amenorrhea. These patients are at risk for diabetes and...

Miscellaneous

The typical history in cases of anovulatory DUB is one of irregular episodes of often painless bleeding occurring in an unpredictable fashion with episodes ranging from a day of spotting to several weeks of continuous, heavy bleeding, often with passage of clots vaginally. Long periods of amenorrhea may or may not be interspersed among bleeding episodes. The cyclic symptoms of mittelschmerz and premenstrual molimina are absent. Patients particularly at risk include postmenarchal teenagers, women with polycystic ovarian syndrome or obesity-related ovulatory dysfunction, and perimenopausal women, up to 50 of whom report episodes of heavy abnormal bleeding. The history will also often provide diagnostic clues when a benign or malignant anatomic lesion is the cause of abnormal bleeding. An enlarging submucosal myoma in a patient with regular menstrual cycles will often present with a regular bleeding pattern associated with a gradually increasing amount and or duration of bleeding over...

Endocrine Evaluation

Peripheral Follicles Polycystic Ovary

As PCOS is diagnosed after exclusion of other endocrine disorders, a work-up to assess for these other conditions is indicated. Table 5.2 summarizes the primary endocrine evaluation. Key to the differential diagnosis is to rule out late onset congenital adrenal hyperplasia due to 21-hydroxylase deficiency. This disorder mimics PCOS as it also presents at menarche and is associated with hyperandrogenism. Unlike PCOS the increased androgens in congenital adrenal hyperplasia are primarily from adrenal origin. A morning blood sample for 17-hydroxyprogesterone is a good screening test for congenital adrenal hyperplasia due to 21-hydroxylase deficiency. Samples should be drawn in the follicular phase if the patient is cycling. Generally levels less than 2 ng mL are not consistent with late onset 21-hydroxylase deficiency. Borderline values should be followed by an ACTH stimulation test. Androgen evaluation should include a serum total testosterone and DHEAS. Hormonal assays for free...

Metabolic Syndrome

Obesity is a component of metabolic syndrome, but it is not absolutely required to make the diagnosis if other criteria are present. Diagnosis of metabolic syndrome is important to alert the clinician of increased risk of diabetes and cardiovascular disease. The prevalence of US adults having the metabolic syndrome is 22 , and it is even more common among high risk groups such as women with polycystic ovary syndrome with about a third of women affected.

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