A Comprehensive Treatment of Polycystic Ovarian Syndrome (PCOS)
by Liqin Zhao
Polycystic ovarian syndrome (PCOS) is one of the most common gynaecological and endocrinal disorders in women. It affects not only the womenís menstrual cycle, but also ovulation and fertility. To be able to treat PCOS and its related infertility effectively, early diagnosis is important. In the article, I will discuss every aspect of treatment, including conventional Western medicine, traditional Chinese medicine theory and pattern differentiation and dietary therapy. Illustrated by case studies, I will also analyse the TCM aetiology and pathology and individualised treatment plan.
Tin Western medicine has been much debated. However, it is generally defined as a disorder of ovulation, with the keyfeature including menstrual cycle disturbance, hyperandrogenism and obesity. There are many extra-ovarian aspects to the pathophysiology of PCOS. It is recognised that 20-33% of the UK female population and 5-10% of women across the world are affected and it is the most common cause of anovulatory infertility [1, 2].
Due to the impaired metabolic and endocrine functions in PCOS, 90% of women with PCOS suffer from irregular menstrual cycles or absent periods , and50-70% of women have insulin resistance, which may further raise the risk of developing diabetes, endometrial cancer, high blood pressure, high cholesterol, and cardiovascular disease . Controlling symptoms as soon as possible can decrease a womanís chance of developing any of these other conditions.
Western Medicine View
Natural ovulation process
Each month approximately twenty follicles (eggs) start to mature, but usually only one egg fully matures, when the fully mature egg is ready, the follicle breaks open to release it, see figure 1. The egg then travels through the fallopian tube for fertilization and implantation in the uterus.
This natural ovulation process depends on optimal function of the sexual hormonal axis, which comprises the hypothalamus, pituitary and ovaries (HPO). The hypothalamus produces gonadotropin releasing hormone (GnRH), which stimulates the pituitary gland to release follicle stimulating hormone (FSH) and luteinising hormone (LH). FSH stimulates the growth of small follicle sacs in the ovaries, while LH supports FSH to ripen the eggs and release a mature egg.
Figure 1. Ultrasound image of a normal ovary.
The causes of PCOS and infertility
PCOS is a controversial condition in WM. It is believed that in 25% of women with PCOS inherit the disorder . Endocrine malfunction and environmental factors may also play a part in the development of PCOS. The majority of women with PCOS have insulin resistanceand the elevated insulin levels contribute or cause the abnormalities seen in the HPO axis that leads to PCOS.
In women with PCOS, the ovaries are much larger than average with a multiple rows of cysts, covered with a thick, slimy, waxy or hard outer coating. These small cysts produce male hormone called androgen. Androgens block follicular development and cause the follicles to degenerate, preventing the release of mature eggs. Androgens can also alter the feedback mechanism within the HPO axis. The overproduction of oestrogen can then cause decreased FSH levels and increased production of LH (this is the reason that many women with PCOS still get an LH surge when they use an ovulation predictor test) and testosterone. Because of this hormonal cascade, the state of the endometrium is affected and ovulation is prevented, therefore no egg is released for fertilization.
PCOS is considered a syndrome because it has a number of unrelated symptoms. It often occurs with one or more of the following factors:
- Dysfunctional uterine bleeding: up to 90% of women with PCOS experiencing irregular menstruation . It is possible to have either very long menstrual cycles with very heavy bleeding, or short menstrual cycles with light bleeding, or even amenorrhea. The menstrual blood contains stringy tissue or mucus, or even watery blood.
- Anovulatory infertility: approximately 74% of women with PCOS have anovulatory infertility , they may still have regular period, but no ovulation, or if an egg is released, it is often later in a womanís cycle and it is of poor quality.
- Recurrent miscarriage: due to poor quality of egg and over stimulation of endometrium, the fertilized egg (if any) is prevented from implanting in the uterus and causes a miscarriage.
- Hirsutism and/or acne: up to 83% of women with PCOS have heavy hair growth, cystic or pustular acne .
- Obesity: 50% of women with PCOS are overweight , their BMI (Body Mass Index) is over 25.
- Ultrasound-scan showing enlarged ovaries with multiple cysts (immature follicles), see figure 2.
- Blood tests: increased LH and testosterone levels, LH / FSH ratio>3, elevated prolactin level, imbalances in sugar metabolism and insulin levels.
Figure 2. Ultrasound images of ovaries with PCOS.
Western medicine treatment
- Birth control pills: can help regulate menstrual cycles, lower levels of androgen, reduce abnormal hair growth and improve acne. It is suitable for women who have irregular periods with very heavy bleeding, but are not trying to conceive. However, symptoms can return if a woman stops taking the pill.
- Fertility medications: Clomiphene citrate (Clomid) to promote ovulation; FSH, such as Gonal-F, Manopur or Puregon to reduce LH level, decrease LH/FSH ratio, correct the biochemical imbalance, improve ovarian function.
- Human chorionic Gonadotropin (HCG) to help mature eggs, and to induce ovulation.
- Diabetes medications: Metformin, Yasmin or Provera to control insulin and blood sugar levels, regulate the production of male hormones, improve the regularity of menstrual cycles.
- Steroids: to balance the androgen hormonal effects, to treat excess or unwanted hair growth and acne. However, over the long term, it can cause liver damage and a reduction of bone density.
- Healthy weight: Maintaining a healthy weight is also a way to manage PCOS. A healthy diet and exercise can lose weight, help the body to use insulin more effectively, lower glucose levels and help regulate menstruation.
- Surgically eliminate follicular cysts:A small portion of the ovary is destroyed by a laparoscopic procedure Ė laser ovarian drilling (in which a small electric current is applied to the ovary), which can decrease the production of male hormones and increase ovulation. It will not help with excessive hair growth and also carries the risk of scar tissue forming on the ovaries. Normally, results only last a few months and then the symptoms return.
- If all of these fail, IUI or IVF may be recommended. However, most women with PCOS donít respond well to any hormonal manipulation that does not address both the health of eggs and the state of ovarian endocrine balance, which may hyper-stimulate the ovaries and create a multitude of side effects. Ovarian hyper-stimulation syndrome (OHSS) is one of the most common and severe conditions seen clinically. Even if a womanís body is forced to ovulate with artificial follicle stimulating drugs, the quality of eggs may be poor. If the woman does become pregnant, consequently, she has a higher risk of miscarriage.
TCM Perspective of PCOS
TCM Aetiology and Pathology
PCOS is classified as amenorrhoea or scanty periods, abdominal masses and/or infertility in terms of TCM. Clinically, PCOS is seen as more of a combination of both an excess and deficient conditions. The organs involved include the Spleen, Kidney and Liver with a subsequent disharmony of Chong and Ren channels. PCOS generally derives from a deficiency of Kidney Yang and Spleen Qi, in its inability to transform, transport and evaporate fluids in the lower burner. The accumulation of water in the pelvic cavity enlarges the ovaries, leading to phlegm-damp and/or blood stagnation, which manifests as abdominal masses.
Kidney Deficiency, Disharmony of Chong and Ren Channels
Constitutional kidney qi deficiency, prolonged illness, excessive sexual activity, long term intake of oral contraceptive pills, can all affect the kidney function and result in the depletion of kidney yin or/and kidney yang, leading to a failure of its ability to dominate the bodyís fluids, warm the uterus with a poor nourishment of chong and ren channels. Therefore, the uterus is unable to get adequate blood flow, causing prolonged menstrual cycle with scanty bleeding or amenorrhea occurs.
Spleen Qi Deficiency, Accumulation of Phlegm and Damp in the Uterus
Over consumption of greasy, fatty and sugary foods, dairy products and alcohol; or excessive worrying and excessive physical work may impair spleen function, causing a failure of transporting fluids and food into useable energy. Accumulated body fluid then transform into damp and phlegm, obstruct the qi and blood flow in the uterus and blocks the chong and ren channels. Consequently, the uterus and ovaries are starved of blood supply, leading to irregular and scanty periods, or even amenorrhea and infertility.
Liver Qi Stagnation and Blood stasis
Enduring stress, depression or anxiety may lead to internal impairment of the seven emotions, causing liver qi stagnation and blood stasis; or invasion of pathogenic wind and cold. Together with excessive consumption of cold foods and drinks, they congeal the blood and cause blood stasis, which obstructs the chong and ren channels and prevents menstruating and therefore amenorrhea. Long term liver qi stagnation could eventually transform into heat, or excessive pathogenic heat invasion exhausts the kidney yin and blood and then causes irregular periods, or heavy and clotty bleeding.
Pattern Differentiations and Treatment
TCM seeks to readdress the entire hormonal environment in PCOS, promote ovulation, improve egg quality, support conception and prevent a miscarriage if a pregnancy is achieved.
Deficiency of Spleen Qi and Kidney Yang, Accumulation of Phlegm and Damp
Clinical manifestations: A prolonged menstrual cycle with scanty bleeding, which contains stringy tissue or mucus or even watery blood, or amenorrhea, or infertility, accompanying with lower back pain, bloated stomach, aversion to cold, fatigue, overweight, heavy facial and body hair, prone to vaginal thrush. Pale and swollen tongue with teeth marks, white and greasy coating, deep and fine pulses.
Treatment plan: Warm up kidney yang and strengthen spleen qi, remove dampness and resolve phlegm.
Patent herbs: Combine You Gui Wan or Nuan Gong Yu Zi Wan with Gui Zhi Fu Ling Wan or Ren Shen Iian Pi wan.
Herbal prescription: Tu Si Zi, Yin Yang Huo, Shu di Huang, Shan Zhu Yu, Gui Zhi, Fu Ling, Dang Shen, Cang Zhu, Ban Xia, Xiang Fu, Zao Jiao Ci, Zhe Bei Mu, Shan Zha.
Deficiency of Kidney Yin and Blood, Liver Qi stagnation
Clinical manifestations: Irregular menstrual periods with light bleeding, or even amenorrhea, severe PMT, depression, restlessness, headache or dizziness, disturbed sleep, night sweats, acne and infertility. Red tongue with thin coating, wiry and fine pulses.
Treatment plan: Nourish kidney yin and blood, soothe liver qi and unblock the chong and ren channels.
Patent herbs: Combine Zuo Gui Wan or Fu Ke Yang Rong wan, with Jia Wei Xiao Yao wan or Chai Hu Shu Gan wan.
Herbal prescription: Shan Yao, Shan Zhu Yu, Mu Dan Pi, Nu Zhen Zi, Han Lian Cao, Gou Qi Zi, Dang Gui, Bai Shao Yao, Chong Wei Zi, Mai Dong, Sheng di Huang, Xiang Fu, Chai Hu.
Blood Stasis, Phlegm and Heat, Blockage of Chong and Ren Channels
Clinical manifestations: Very irregular menstrual cycle with no pattern at all, scanty bleeding with clots, or amenorrhea, although may flood sometimes, infertility, distension of chest and breasts, bloated stomach and cramping in the lower abdomen, severe acne, heavy body and facial hair, thirsty, constipation and overweight. Dark red or purple red tongue with black spots around the edge, white or yellow greasy coating; wiry, slippery and rapid pulses.
Treatment plan: Clear heat and remove phlegm, motivate blood and resolve blood stasis.
Patent herbs: Combine Xue Fu Zhu Yu Wan or Fu Ke Tiao Jing Wan, with Chai Hu Shu Gan Wan or Qing Qi Hua Tan Wan.
Herbal prescription: Tao Ren, Dan Shen, Dang Gui, Chuan Xiong, Fu Ling, Mu Dan Pi, Chi Shao Yao, Xiang Fu, Zhi Ke, Chong Wei Zi, Zao Jiao Ci, Xia Ku Cao, Hai Zao, Zhe Bei Mu.
For complicated cases with multiple patterns, an artificial menstrual regulatory treatment with herbal medicine and acupuncture may be applied.
Commonly used points:
Baihui (DU 20), Tianshu (ST 25), Guilai (ST 29), Zhongji (REN 3);
Moxibustion on Guanyuan (REN 4), Qihai (REN 6) and Shenque (REN 8);
Electro-acupuncture on Shenshu (UB 23), Ciliao (UB 32), Zhishi (UB 52).
Modification of points:
- For strengthening spleen qi: Zusanli (St 36), Xuehai (SP 10), Fenglong (ST 40), Yinlingquan (SP 9), Sanyinjiao (SP 6), Pishu (UB 20).
- For warming kidney yang: Shenshu (UB 23), Dachangshu (UB 25), Mingmen (Du 4), Yaoyangguan (DU 3), Fuliu (KI 7), Zhaohai (KI 6).
- For nourishing kidney yin: Shenshu (UB 23), Taixi (KI 3), Sanyinjiao (SP 6), Neiguan (PC 6).
- For soothing liver Qi and resolving blood stasis: Geshu (UB 17), Ganshu (UB 18), Waiguan (SJ 5), Hegu (LI 4), Sanyinjiao (SP 6), Taichong (LV 3), Zulinqi (GB 41).
Most women with PCOS have endocrine abnormalities affected by diet, losing weight can help treat PCOS. Fat cells store oestrogen, and usually there is relatively too much circulating oestrogen and LH, The liver metabolizes these hormones, so a healthy functioning liver is also crucial for proper insulin balance.
- Cut out all forms of refined sugar and carbohydrates, which include white bread, paste, white rice, rice cakes, most breakfast cereals or any starchy, low fibre food.
- Avoid sweeteners, soda, fruit juice and any drinks that rapidly raise the blood sugar level.
- Consume adequate amounts of protein, such as lean meat, and soybean products.
- Eat plenty vegetables, but preferably slightly cooked.
- Eat only complex whole grains like oatmeal, brown rice and whole wheat.
- Avoid cold food, ice cold drinks, milk and dairy products.
- Eliminate alcohol and caffeine.
- Exercise regularly.
PCOS & Recurrent Miscarriages
Medical history: Helen, aged 33, HR advisor.
She had two miscarriages at the age of 25, then conceived and delivered her daughter at 26. Her period was 28 days cycle until December 1997 when she started taking oral contraceptive pills. She had been trying for a second child since January 2002 when she came off the pill, but had no menstruation for 6 months and then suffered from very irregular periods ever since. She had only two menstrual periods between March 2005 and December 2005 and was diagnosed with PCOS. She had been taking Clomid since April 2006 for 9 months, had achieved a pregnancy in November 2006, but miscarried again at 6 weeks. She had visited me after that miscarriage, the main symptoms were: stress, depression, anxiety, fatigue, prolonged period with scanty bleeding. Her tongue was pale with thin coating and black spots on the edge, deep and fine pulses.
Differentiation: Spleen qi deficiency with blood stasis.
Treatment plan and progress:
Chinese herbal powders were given every day combined with acupuncture weekly.
1st visit (Day 7 of cycle): modified Ba Zhen Yi Mu Tang and Nuan Gong Yun Zi Tang.
2nd visit (Day 14 of cycle): modified Zhu Yun Tang plus Tao Hong Si Wu Tang.
3rd visit (Day 21 of cycle): had ovulation pain and vaginal fertile mucus, test confirmed ovulation was on day 19 of cycle. Modified Tiao Jing Cu Yun Tang plus Cong Run Bu Shen tang.
4th visit (Day 28 of cycle): Modified Tiao Jing Bu Xue Tang.
5th visit (Day 35 of cycle): feeling tired and sick, pregnancy test was positive.
She continued treatment weekly until 12 weeks of pregnant and delivered a baby boy in October 2007.
PCOS is a rather common and complicated gynaecological condition. It is considered a syndrome because it has a number of unrelated symptoms, and usually occurs with one or more of symptoms, therefore it is often misdiagnosed at an early stage, or it may take a long process before making a diagnosis by WM and is left untreated until trying to conceive. In my clinical practice, many women come with infertility issues, they may have already gone through several failed IVF attempts, but the actual underline cause was PCOS. TCM combine with dietary therapy is the most optimum and effective treatment for PCOS and its related infertility. Here I summarise some key factors:
- PCOS is believed as a combination of both excess and deficient condition, which usually affects the organs: kidney, spleen, liver and chong and ren vessels. The most commonly seen patterns are: deficiency of spleen Qi and kidney yang, accumulation of phlegm and damp; deficiency of kidney yin and blood, together with liver qi stagnation; blood stasis with phlegm and heat, blockage of chong and ren vessels.
- TCM treatment should focus on strengthening spleen Qi and kidney yang to remove damp and phlegm, soothing liver qi to motivate blood and resolve blood stasis, unblock the chong and ren channels.
- IVF treatment may be necessary for some women if other fertility issues are also involved, for example male factor infertility. However, women with PCOS often donít respond well to hormonal stimulation drugs used in the IVF treatment, they either produce very few eggs with poor quality, and consequently poor fertilization; or suffer from OHSS, which can be life threatening. Therefore, TCM treatment is advisable before the IVF to prepare their body to be in the best possible condition and produce the best response to IVF treatment.
- TCM treatment should be continued during early pregnancy to minimise the risk of miscarriage.
Dr. Zhao graduated from the Henan University of TCM in 1985, and is qualified in both TCM and Conventional Western Medicine. She has been practise acupuncture and Chinese medicine in the UK since 1995, has developed her unique TCM programme for women with infertility and RSM. She has been work in collaboration with CARE (the largest independent fertility treatment provider in the UK), and some gynaecological and reproductive consultants in UK hospitals.
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