Dr. Sushma Sadula
Polycystic Ovarian Syndrome (PCOS)
It affects 6-10% of women, amounting to 5 million women in the United States alone. Due to the presence of polycystic ovaries on ultrasound, it was considered a gynecologic condition. Now it is known that polycystic ovaries are only one of its manifestations and the syndrome has many causes, symptoms, and signs. We now know that the condition is metabolic and endocrine. It causes resistance to insulin and high levels of insulin. The increased insulin then stimulates the ovaries to produce male hormones (androgens like testosterone and a decrease in sex hormone binding globulin (proteins that bind to hormones and reduce the amount of circulating free hormones). The causes of PCOS are poorly understood. It is considered to be a multifactorial disease with uncontrolled ovarian hormone production, anomalous insulin signaling, inflammation from oxidative stress, and genetic and environmental factors.
In normal menstrual cycles, gonadotropin releasing hormone (GnRH) is secreted in a pulsatile manner from the hypothalamus (a gland at the base of the brain) which stimulates the pituitary gland (another gland located near the hypothalamus) to release follicle stimulating hormone (FSH) and luteinizing hormone (LH). FSH and LH act on the ovaries to produce sex hormones and development of follicles so that the ovary can release an egg (ovum) at the time of ovulation. LH stimulates the production of both androgens and progesterone. FSH stimulates the production of an enzyme called aromatase which converts the androgens to estrogen. Estrogen nourishes the follicles to develop a strong ovum. Androgens inhibit follicular development. Once estrogen reaches a peak concentration in the general bloodstream, this stimulates a surge of LH. The LH surge stimulates ovulation and the release of the ovum.
In PCOS, the GnRH pulsatile frequency is higher than normal and leads to elevated levels of LH and FSH in the general bloodstream. The LH:FSH ratio is imbalanced and leads to the production of androgens: androstenedione and testosterone. The FSH stimulates follicular development so immature follicles develop but none develop into a mature follicle. Estrogen levels are also elevated due to conversion of androstenedione to estrogen. Since a mature follicle isn’t produced and there is an imbalance of LH, FSH, androgens, and estrogen, ovulation doesn’t occur and leads to chronic anovulation (absence of ovulation). Progesterone is basically absent and there is a vicious cycle of enhanced pulsatility of GnRH, high LH, low FSH and anovulation. The elevated androgens are responsible for acne, facial hair, and male pattern balding. The anovulation leads to missed periods. The lack of progesterone leads to heavy periods when periods do occur.
Functional medicine offers a holistic approach to treating PCOS by addressing the root causes of the condition rather than just treating the symptoms. PCOS is associated with hormone imbalances, insulin resistance, inflammation, and lifestyle factors. As a functional medicine physician, I work closely with my patients to understand their unique triggers and tailor treatments including dietary changes, targeted herbal supplements, stress management, and hormonal support. By improving insulin sensitivity, reducing inflammation, and balancing hormones naturally, functional medicine can help regulate menstrual cycles, improve fertility, manage weight, and reduce the risk of long-term complications associated with PCOS, such as diabetes and cardiovascular disease. This approach empowers women to take control of their health and well-being with personalized care.
- Dr. Sushma Sadula
There appears to be a strong genetic predisposition to the development of PCOS. The Rotterdam criteria is an algorithm for diagnosing PCOS. The criteria includes high circulating androgens, oligo or anovulation (reduced or absent ovulation), and polycystic ovaries noted on ultrasound. A woman only needs 2 out of 3 of these criteria to be diagnosed with PCOS. A phenotype is the expression of a disease. Possible phenotypes of the Rotterdam criteria include high androgens and polycystic ovaries, high androgens and anovulation, polycystic ovaries and anovulation, high androgens, polycystic ovaries and anovulation. There are two other criterias called National Institute of Health (NIH) and the Androgen Excess and PCOS Society (AES). Between these three criteria, there are 10 possible phenotypes and possibly 5 more phenotypes outside of these criteria. Checking for these phenotypes helps to diagnose a woman with the condition.
It is very important to diagnose and treat women with PCOS.
Polycystic Ovarian Syndrome or PCOS is the most common endocrine disorder in women of reproductive age.
Women with PCOS are at a higher risk of diabetes and glucose intolerance.
Women with PCOS are more likely to be overweight or obese compared to women without PCOS. They are at higher risk for diabetes. Even leaner women with PCOS can have insulin resistance and higher risk of diabetes. PCOS increases the risk of cardiovascular disease, high cholesterol, sleep apnea, fatty liver disease, endometrial cancer, depression, anxiety, pregnancy complications, and anovulatory infertility. Different phenotypes have different risks. This is an under-recognized condition with serious implications if left untreated.
Functional medicine emphasizes a diet rich in whole, unprocessed foods to help regulate insulin levels and reduce inflammation. A low glycemic diet focused on vegetables, lean proteins, and healthy fats can improve insulin sensitivity and encourage hormone balance. Removing dairy, gluten, and other food triggers can reduce inflammation. Gut health is very important. The microbiome can be assessed for imbalances and can be treated with herbs, fiber, prebiotics, and probiotics to improve digestion and reduce inflammation, while addressing underlying gut issues like leaky gut syndrome. By supporting the adrenal and thyroid glands, functional medicine can help restore overall hormonal balance. Adaptogenic herbs like ashwagandha and rhodiola can help with stress management and hormone balance. Botanicals like Vitex chaste berry can help support reproductive hormone balance by supporting regular ovulation and progesterone production by the ovaries. Specific supplements like inositol, omega-3-fatty acids, and vitamin D are often recommended to support insulin sensitivity, reduce androgen levels, and regulate menstrual cycles. A personalized exercise plan focusing on strength training and walking can help regulate insulin and improve hormone function. Chronic stress can exacerbate PCOS symptoms by disrupting hormone balance. Functional medicine integrates stress management techniques like meditation, yoga, and mindfulness.
