PCOS and Infertility

By Jack Handlin L.Ac., DAOM, FABORM

Overview:

Polycystic ovarian syndrome (PCOS) is one of the most common anovulatory disorders and the most common hormonal cause of female infertility. It is estimated that roughly 10% of women have PCOS.

The absence of periods or irregular periods is the primary indication that PCOS may be present. Other symptoms that often accompany PCOS are: weight imbalance, acne, excess facial and/or body hair, thinning of head hair. There may also be high lipid levels as well as imbalance of the sugar metabolism. Some women with PCOS do not present with symptoms.

The 1990 NIH conference concluded that the two most consistent elements of PCOS are the presence of elevated androgenic hormones (male hormones) and chronic lack of ovulation.

In PCOS, hormonal dysfunction results in the ovaries not being able to fully mature and release an egg. Although follicles begin to mature they stall and none get far enough to be released. In this case ovulation does not occur and as a result the underdeveloped follicles turn into fluid-filled sacs know as cysts.

These cysts and surrounding tissue produce male hormones called androgens. These androgens block the follicular development and cause the follicles to degenerate, preventing the release of mature health eggs. These androgens enter the blood stream and affect the feedback mechanisms between the (HPO) hypothalamus-pituitary-ovarian axis .

This increases the amount of estrogen in the blood stream in relation to progesterone, leading to an increased production of luteinizing hormone (LH) and testosterone. It is this interplay between the hormones that prevents ovulation from occurring.

Within normal follicular development follicles mature within the ovaries over many months in an estrogen and progesterone rich environment, not in and androgenergic environment.

When a woman’s body is forced to ovulate with Western medication the quality of her eggs may be poor, which decreases her chances of a sustaining a viable pregnancy and may put her at a greater risk for miscarriage. This is an area where acupuncture and Chinese herbal medicine can greatly assist Western treatments for PCOS.

Possible Cause:

Western science has not uncovered the exact cause leading to PCOS but some possible mechanisms appear to be an abnormal insulin and glucose interaction. Excess insulin circulation in the blood stream seem stimulate enzymes that help manufacture androgens in the ovaries. Imbalance of insulin production can also contribute to obesity, which may be one of the reasons that many women with PCOS are overweight.

Another possible explanation may be due to adrenal germination. Suggesting if a patient has strong stimulation of the adrenals in childhood, then at puberty the reticular zone of the adrenals secretes excessive testosterone, which transforms into high levels of estrone disrupting the (HPO) axis setting of a cascade of events leading to multiple follicles producing high estrogen ultimately leading to a decrease of FSH levels.

Western Drug Treatments:

When women are diagnosed with PCOS and infertility they are often prescribed drugs such as clomiphene, hCG, and gonadotropin. If these drugs are not affective, IVF and other ART therapies are often recommended.

Many women don’t respond well to hormonal manipulation that does not successfully address both the health of the egg and the state of the ovaries.

This involves endocrine balance in the ovaries 3-6 months prior to ovulation and fertilization. This is where Chinese medicine can offer hope and a great advantage to assist Western medicine treatments.

Thin Type PCOS vs. Overweight Type PCOS:

Relative Hyperandrogenism vs. Hyperandrogenism

The mechanisms causing PCOS in thin women differ from that of overweight women. In heavier women, PCOS often occurs because of the excess of androgen production disrupting the balance of androgen to estrogen ratio know as ‘hyperandrogenism’.

This differs in thin women because many don’t have excess androgen production, but often present with lower estrogen levels. Estrogen comes from two places in the body, the ovaries and fat cells. In very athletic and/or women with a low percentage of body fat estrogen levels can be low. So as a result the androgen to estrogen ratio is still out of balance, not because androgens are high, but because estrogen levels are low. This still results in high levels of androgens in comparison to estrogen levels referred to as ‘relative hyperandrogenism’. The treatment goals in both types is to correct the androgen to estrogen ratio.

In an article written by the Jarret Fertility Group, they suggest looking at the past history for brief exposures to elevated androgen levels that may set up a developing cycle of abnormal follicular growth and function.

Two key questions they ask are, “what is the least you have weighed in your life,” and “were you an athlete.” They suggest that in thin, athletic women who do not have regular periods this may not only be due to an imbalance with the hypothalamus, because ultrasounds reveal these women often have changes consistent with PCOS.

Both types usually have a form of insulin resistance. We usually think of a high glycemic diet causing high blood sugars leading to insulin resistance. Lack of sleep and chronic stress can also lead to high insulin levels, which is often seen in women with thin type PCOS. In this case we focus our treatment more on stress reduction than weight loss. We recommend the 'The New Glucose Revolution Guide To Living Well With PCOS' as a good recourse to assist regulating insulin levels and optimize fertility.

Whether thin type or overweight type PCOS it is important to balance androgen to estrogen relationship before conception both naturally and undergoing ART therapies such as IVF, IUI, IVM & GIFT.

Stay tuned for our following post 'Acupuncture In The Treatment of PCOS and Infertility'

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