New Treatment of Polycystic Ovarian Syndrome

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! More here...

The Natural Pcos Diet Overview


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The A-z Of Pcos Symptoms And How To Treat Them Naturally

This e-book is a .pdf file which uses Adobe Reader or can be open with your internet browser, and contains 48 pages and has an A-Z of Pcos Symptoms and information about one or more natural treatments for each symptom. Some treatments can be used to treat more than one symptom which makes it even easier to include in your lifestyle.

The Az Of Pcos Symptoms And How To Treat Them Naturally Overview

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The ovary is the preferential source of testosterone it is estimated that 75 of circulating testosterone originates from the ovary (mainly through peripheral conversion of prohormones by liver, fat, and skin, but also through direct ovarian secretion). Androstene-dione, of both adrenal (50 ) and ovarian (50 ) origin, is the only circulating androgen that is higher in premenopausal women than in men, yet its androgenic potency is only 10 that of testosterone. However, it is often elevated in PCOS patients. Dihydrotestosterone (DHT) is the most potent androgen, although it circulates in negligible quantities, and results primarily from the intracellular 5a-reduction of testosterone. Thus circulating testosterone may be the androgen of choice to measure indeed, its circulating levels may offer better discrimination between a control population and the affected population with PCOS. A 14 overlap in elevated androgen levels was noted between women with PCOS and a prospectively recruited...

Polycystic Ovaries On Ultrasound

Different authors have defined PCOS on the basis of the morphology of the ovary found on ultrasound, with multiple 2- to 8-mm subcapsular preantral follicles forming a black pearl necklacesign (47). Polycystic ovaries are found in a wide variety of unrelated disorders, including in up to 30 of women with normal menses and normal circulating androgens (35,36,48). The differential diagnosis of polycystic ovaries is extensive, with some syndromes having little overlap with hyperandrogenic chronic anovulation. There have been reports suggesting that polycystic ovaries per se may identify a group of women with some further stigmata of reproductive and metabolic abnormalities found in the endocrine syndrome of PCOS (49,50), but the data have not been consistent (51). It is important to note that not all women with the endocrine syndrome of PCOS have polycystic-appearing ovaries (51), and that polycystic ovaries alone should not be viewed as synonymous with PCOS. Polycystic ovaries appear to...

Treatment Of Pcos

We are currently changing from a symptom-oriented treatment approach to PCOS, which often focused alternatively on either suppression of the ovaries (for hirsutism and menstrual disorders) or stimulation of the ovaries (for infertility), to one that improves insulin sensitivity and treats a variety of stigmata simultaneously (111). Multiple studies have shown that improving insulin sensitivity, be it from lifestyle modifications or from pharmacologic intervention, can result in lowered circulating androgens (primarily mediated through increased SHBG and less bioavailable androgen but also through decreased total testosterone), spontaneous ovulation, and spontaneous pregnancy.

P Michael Conn Series Editor

Weetman, 2007 When Puberty is Precocious Scientific and Clinical Aspects, edited by Ora H. Pescovitz and Emily C. Walvoord, 2007 Insulin Resistance and Polycystic Ovarian Syndrome Pathogenesis, Evaluation and Treatment, edited by John E. Nestler, Evanthia Diamanti-Kandarakis, Renato Pasquali, and D. Pandis, 2007 Hypertension and Hormone Mechanisms, edited F. Kushner and Daniel H. Bessesen, 2007 Androgen Excess Disorders in Women Polycystic Ovary Syndrome and Other Disorders, Second Edition, edited by Ricardo Azzis, John E. Nestler, and Didier Dewailly, 2006


In the broadest definition, PCOS has been identified by the World Health Organization as type 2 ovulatory dysfunction, or normoestrogenic anovulation. Although chronic anovulation (6 to 8 spontaneous episodes of vaginal bleeding per year) may be the sine qua non of the syndrome, only a small percentage of women with PCOS are completely amenorrheic. The majority are oligomenorrheic and experience varying intervals of vaginal bleeding. The cause of this vaginal bleeding may be physiologic (postovulatory withdrawal bleed) or pathologic. The baseline endogenous ovulatory frequency is unknown in an untreated PCOS population but the ovulation rate in the largest randomized controlled trial in women with PCOS to date demonstrated an almost 30 ovulatory frequency in the placebo-treated arm, indicating either a significant placebo effect and or a high endogenous rate (29).

Type 2 Diabetes Mellitus

Retrospective studies looking at diabetes prevalence over time have generally noted an increased prevalence with age in women with PCOS. Studies from Scandinavia have shown increased rates of type 2 diabetes and hypertension compared with controls (53). This study used a combination of ovarian morphology and clinical criteria to identify women with PCOS and found that 15 had developed diabetes, compared with 2.3 of the controls (53). A case-control study of PCOS in the United States has shown persistent Fig. 1. Glucose (top panel) and insulin (bottom panel) concentrations obtained during a 75-g oral glucose tolerance test (OGTT) in 408 premenopausal women with PCOS ( positive family history) and without (O negative family history) a family history of type 2 diabetes. Adapted from ref. 60. Fig. 1. Glucose (top panel) and insulin (bottom panel) concentrations obtained during a 75-g oral glucose tolerance test (OGTT) in 408 premenopausal women with PCOS ( positive family history) and...

Cardiovascular Risk Factors

Patients with PCOS may have abnormal lipid profiles, including elevated triglyceride, LDL cholesterol, VLDL cholesterol, and decreased HDL. In a study of more than 200 patients with PCOS, Talbott et al. found increased BMI, insulin, triglyceride, cholesterol, LDL, and blood pressure (72). The elevated insulin levels were found to correlate with the increased cardiovascular risk independently in PCOS patients. The metabolic profile noted in women with PCOS is similar to insulin resistance syndrome, a clustering within an individual of hyperinsulinemia, mild glucose intolerance, dyslipidemia, and hypertension (73). There is a prolific literature identifying obesity, dyslipidemia, glucose intolerance, diabetes, and occasionally hypertension as risk factors for cardiovascular disease in women with PCOS (74-79). However, there is actually little published evidence supporting a link between PCOS and cardiovascular events i.e., increased mortality from CVD, premature mortality from CVD, or...

Pregnancy Complications

PCOS is associated with increased risk for recurrent miscarriage. When using ovarian morphology as surrogate marker, polycystic ovaries were identified in 82 of women presenting with recurrent miscarriage (101). However, the risk of early first-trimester pregnancy loss in women with PCOS is estimated to be 30 , compared with about 15 to 20 in the general population (102,103). Pregnancy complications (gestational diabetes, pre-eclampsia, infants who are small for gestational age, preterm labor, and stillbirth) also appear to be high in patients with PCOS (104-107), although there are reports that did not find such a connection (108,109). Currently, the underlying pathogenesis of early pregnancy loss and pregnancy complications in PCOS is thought to be the result of a combination of several interrelated factors, which include hyperandrogenaemia, insulin resistance, obesity, abnormal folliculogenesis, and infertility therapy itself (110).

Ovarian Suppressive Therapies

Table 3 Treatment of PCOS A GnRH agonist may cause greater lowering of circulating androgens, but comparative trials against other agents and combined agent trials have been mixed and have not shown a greater benefit to one or the other or combined treatment (113-116). A GnRH agonist given alone results in unacceptable bone loss (116). Glucocorticoid suppression of the adrenal glands also offers theoretical benefits, but deterioration in glucose tolerance is problematic for women with PCOS, and long-term effects such as osteoporosis are significant concern. It may be useful as adjunctive therapy in inducing ovulation with clomiphene citrate.

Exercise Lifestyle Modification

There is some evidence that lifestyle modification (diet and exercise) may be an effective adjunct to the treatment of PCOS. The use of hypocaloric diets improves the metabolic derangements in those patients, and low-calorie, low-fat diets have been shown to improve clinical parameters and lower insulin and testosterone levels in PCOS patients (169,170). Weight reduction has also been shown to increase noradrenalin sensitivity in PCOS patients, as PCOS patients have a marked reduction in the lipolytic effects of noradrenalin owing to a decreased number of noradrenalin receptors on fat cells (171), resulting in dyslipidemia. Metformin, in addition to a hypocaloric diet, improves hirsutism, menstrual function, visceral adipose tissue, and glucose-stimulated insulin secretion (172,173). Thus, it appears that diet and medication in combination may be helpful in patients with PCOS. It is reasonable to assume that exercise would have the same beneficial effects in women with PCOS as in...

Type 1 diabetes and menopause

Age.24' Genetic factors, including haplotypes found in association with the DR4 haplotype (more common in type 1 diabetes), may increase the risk of early menopause two-fold. The long-term effects of premature menopause, in addition to a shorter time for childbearing, include a higher risk of cardiovascular disease, abnormal lipid profile, and increased risk of osteoporosis. Earlymenopause may occur in women with type 1 diabetes from autoimmune premature ovarian failure (similar to the autoimmune thyroiditis seen more commonly in patients with type 1 diabetes), from peripheral hyperinsuline-mia and hyperandrogenemia seen in polycystic ovary syndrome, and from hypothalamic dysfunction from poorly controlled diabetes. A good menstrual history will help with the early detection of premature menopause in these women.

Treatment of Infertility

Clomiphene citrate (CC) has traditionally been the first-line treatment agent for infertility in women with PCOS. It is a nonsteroidal agent and a member of a large family of triphenylethylene derivatives, which includes clorotrianisene and tamoxifen (both of which compare favorably to CC in inducing ovulation). It is a racemic mixture of two isomers, zuclomiphene (longer-acting) and enclomiphene (more potent in inducing ovulation) (140). Clomiphene has a long half-life only 51 of the oral dose is excreted after 5 d and the zu isomer can be detected in the serum for up to 1 mo after treatment (141). Clomiphene is thought to work as a selective estrogen receptor modulator (SERM) acting as an estrogen antagonist at the hypothalamic-pituitary axis and stimulating GnRH secretion. A meta-analysis showed CC to be effective in patients with ovulatory dysfunction similar to PCOS (142). Compared with placebo, CC was associated with increased ovulation. CC (all doses) was associated with an...

Obstetrics and Gynecology

The answer is a. (DeCherney, 8 e, pp 668-669.) The most common cause of postmenopausal vaginal bleeding is atrophic vaginitis (with or without trauma). Endometriosis is the most common cause of infertility patients present with dyspareunia (painful intercourse), abnormal vaginal bleeding, and pelvic pain. Uterine leiomyomas (uterine fibroids) change in size with the menstrual cycle but regress in size during menopause. Often the fibroid is palpable on pelvic examination. Polycystic ovarian syndrome (Stein-Leventhal syndrome) affects younger women (15-30). The etiology of polycystic ovary syndrome is unknown patients present with amenorrhea, obesity, hirsutism, and infertility. All postmenopausal women with vaginal bleeding require a biopsy to rule out endometrial carcinoma.

Insulin Sensitizing Agents

Drugs developed initially to treat type 2 diabetes have also been utilized to treat PCOS. None of these agents are currently FDA-approved for the treatment of PCOS or for related symptoms such as anovulation, hirsutism, or acne. These include metformin (117-119), thiazolidinediones, and an experimental insulin sensitizer drug, d-chiro-inositol (120). There have been no reported abnormalities associated with the use of metformin during pregnancy in women with diabetes (121-123) or in women with marked hyperandrogenism during pregnancy (124), or to the small number of women with PCOS who have conceived during treatment (125-127). The combination of metformin and clomiphene markedly improves ovulation in PCOS patients by correcting the underlying metabolic problem. Metformin, in a meta-analysis of 13 studies in women with PCOS, was shown to significantly reduce fasting insulin levels even in this heterogeneous population (128). Fasting glucose also had a small reduction. Lipid profile...

Romana Dmitrovic md and Richard S Legro md

Oligomenorrhea Amenorrhea Hyperandrogenemia Hyperandrogenism Polycystic Ovaries on Ultrasound Long-Term Consequences Treatment of PCOS Polycystic ovary syndrome (PCOS) is a common but poorly understood endocrinopathy diagnosed by the combination of oligomenorrhea, hyperandrogenism, and polycystic ovaries. Many of the women with PCOS are also uniquely and variably insulin-resistant. This can manifest as hyperinsulinemia, glucose intolerance, and frank diabetes. Affected women are plagued by infertility, menstrual disorders, dysfunctional uterine bleeding, and peripheral skin disorders including acne and hirsutism. The etiology of the syndrome is poorly understood. Many, if not most, US women with PCOS are also obese, which exacerbates many of the symptoms of the syndrome. This suggests that lifestyle interventions should be the first line treatment for these obese women. Treatment tends to be symptom-based, although some treatments can address multiple presenting complaints. The two...

Tall Stature

Tall stature is usually a normal variant, familial tall stature. Exogenous obesity can also cause tall stature. Endocrine causes of tall stature include growth hormone excess (gigantism, acromegaly), androgen excess (tall as children but short as adults), and hyperthyroidism. Genetic syndromes and metabolic disorders responsible for tall stature include homocystinuria, cerebral gigantism, Beckwith-Wiedemann, Weaver-Smith, and Klinefelter syndromes. Homocystinuria is autosomal recessive, with an incidence of 1 200,000. Patients have a Marfanoid appearance with associated mental retardation or psychiatric illness. Cerebral gigantism (Sotos syndrome) are large for gestational age, have mental retardation, and a mild hydrocephalus.

Diagnosing Diabetes

IGT is not defined by clinical signs and symptoms but strictly by plasma glucose levels alone. This state has also been referred to as chemical diabetes, borderline diabetes, or prediabetes. Although these patients do not yet have the microvascular complications of diabetes mellitus they are at risk for, and begin to develop, macrovascular complications caused by arteriosclerotic deposition secondary to the hyperglycemic state and are at significant risk for developing diabetes, especially when associated with concomitant risk factors of hypertension, body mass index (BMI) greater than 25 kg m2, sedentary lifestyle, dyslipidemia (especially increased small, dense low-density lipo-proteins LDL and increased triglycerides), history of gestational diabetes, polycystic ovaries and associated ethnicity (African American, Latin American, Native American, and Pacific Islanders) (13).


Increased testosterone levels in males can be caused by adrenal hyperplasia and adrenocortical or testicular tumors. Young men with an excess of this hormone may display precocious puberty and sexual behavior. Ovarian and adrenocortical tumors, adrenocortical hyperplasia, and polycystic ovaries may cause elevated testosterone levels in females. Excessive amounts of testosterone usually lead to the masculiniza-tion of females as evidenced in hirsutism, cessation of menstrual periods, and development of other male secondary sex characteristics.

The Biguanides

In the Biguanides and Prevention of the Risks in Obesity (BIGPRO) trial (12) in 1994, nondiabetic patients lost weight with metformin, although it is not approved for use in this setting. Metformin has also been shown to be efficacious in patients with polycystic ovaries and in patients with impaired glucose tolerance, although metformin does not have official endorsement for these indications at this time.

Insulin Hypothesis

The discovery of hyperinsulinemia (13) and insulin resistance in women with PCOS (15). This leads to overproduction of insulin to compensate for the perceived lack of effect, and over time to P-cell exhaustion and ultimately type 2 diabetes. There is now a relatively substantial body of literature confirming P-cell dysfunction in PCOS, although as in diabetes, there is still considerable debate as to the primacy of the defects and their worsening over time (16). Women with PCOS may have hyperinsulinemia, insulin resistance, impaired glucose tolerance, or diabetes mellitus (13,17,18). The increase in insulin resistance in women with PCOS compared with appropriate controls ( 5-40 ), is of a similar magnitude to that seen in type 2 diabetes and is independent of obesity, glucose intolerance, increases in waist-to-hip ratio, and differences in muscle mass (14). Basal insulin levels are increased and insulin secretory response to meals has been shown to be reduced in women with PCOS (19),...


Chronic anovulation is the cause of the most common reason that women with PCOS present to the gynecologist infertility (30). As a general rule, PCOS patients represent one of the most difficult groups in which to induce ovulation both successfully and safely. Many women with PCOS are unresponsive to clomiphene citrate and human menopausal gonadotropins, and this is exacerbated by underlying obesity. On the other end of the spectrum are PCOS patients who overrespond to both these medications. Women with PCOS are at especially increased risks of ovarian hyperstimulation syndrome (OHSS), a syndrome of massive enlargement of the ovaries and transudation of ascites into the abdominal cavity that can lead to rapid and symptomatic enlargement of the abdomen, intravascular contraction, hypercoagulability, and systemic organ dysfunction (31). There is also emerging evidence that baseline hyperinsulinemia may contribute to the increased OHSS risk (32,33). Women with PCOS are also at increased...


Hirsutism is defined as excess body hair in undesirable locations and, as such, is a subjective phenomenon that makes both diagnosis and treatment difficult. Most commonly hirsutism associated with PCOS tends to be an androgen-dependent, midline-predominant hair growth. It is important to note that other factors than androgen action Hirsutism is heterogeneous and a common disorder with features similar to PCOS, but only 50 of women with hirsutism may actually have PCOS (41). Hirsutism is also not invariably present in a woman with PCOS. There are, for instance, ethnic differences in target tissue sensitivity to circulating androgens and intracellular androgens (42), such that marked androgen excess may not manifest as hirsutism (Asians, for example) (40). Methodology of the assessment of hirsutism and response to treatment has been poorly validated (43). Hirsutism scores are notoriously subjective (44), and even the most frequently utilized standard of subjective hirsutism scores, the...


Obesity has become epidemic in our society and contributes substantially to reproductive and metabolic abnormalities in PCOS. Obesity is defined by body mass index (BMI body weight in kilograms divided by height in meters2) of 30 kg m2 or more (62). However, BMI does not take into account patient habitus, so central obesity, which is often present in patients with PCOS, can be diagnosed clinically by measuring the waist circumference (WC) or waist-to-hip circumference ratio (WHR) (62). WC larger than 102 cm for men and 88 cm for women, or WHR greater than 0.95 in men and 0.85 in women in obese individuals with BMI between 25.0 and 34.9 kg m2 confer high risk for diabetes, hyperlipidemia, hypertension, atherosclerosis, and insulin resistance (63-67). Obesity is present in about 50 of patients with PCOS. Both insulin resistance and hyperinsulinemia are magnified in the presence of obesity (68,69). Unfortunately there are no effective treatments that result in permanent weight loss, and...

Risk for Malignancy

Endometrial cancer is the most commonly diagnosed invasive gynecological cancer in women. Case series have identified women with PCOS at high risk for developing endometrial cancer and often at an early age (88-91), but there is actually little solid epidemiologic evidence to link PCOS and endometrial cancer (92). A stronger association between PCOS and endometrial cancer may be possible if we were able to make the diagnosis of PCOS in menopausal women, but a diagnosis based on hyperandrogenic chronic anovulation becomes difficult to make after ovarian failure and cessation of menses (93). The mechanism by which women with PCOS may be at increased risk for endometrial hyperplasia and endometrial cancer is thought to be chronic stimulation of the en-dometrium with weak but bioactive estrogens, combined with the lack of progestin exposure. This condition, known as Unopposed estrogen,'is perhaps the clearest hormonal risk factor for endometrial cancer (94). Women with PCOS have been...

Anti Obesity Drugs

Apart from diet, combination with pharmacological treatment with metformin or with weight-reducing agents has been used when required for further weight reduction. It has been reported that the combination of a low-calorie diet with metformin treatment induced greater reduction of body weight and visceral obesity in women with PCOS compared with a low-calorie diet and placebo treatment (136). Weight-reducing agents have been shown to increase the effect of lifestyle modification in reducing the incidence of type 2 diabetes in obese patients (137), and similar effects have been noted in women with PCOS. Sibutramine treatment alone and in combination with ethinyl estradiol and cyproterone acetate in obese women with PCOS has been found to have positive effects on clinical and metabolic risk factors for cardiovascular disease (decrease in waist-to-hip ratio, blood pressure, triglycerides, and insulin levels) (138). Furthermore, orlistat treatment in obese women with PCOS induced a more...

Surgical Treatment

Stein and Leventhal performed ovarian wedge resection more than 80 yr ago and noted regular menses and spontaneous pregnancy in some patients (2). Many studies utilizing ovarian wedge resection or ovarian drilling have been performed over the years, some with impressive results. The beneficial influence of such destructive ovarian interventions has been suggested (163-165), but not proven, and the value of laparoscopic ovarian drilling as a primary treatment for subfertile patients with anovulation and PCOS is undetermined according to a Cochrane review (166). There is insufficient evidence to determine a difference in ovulation or pregnancy rates when compared with gonadotropin therapy as a secondary treatment for clomi-phene-resistant women (166), although a recent study suggested that the pregnancy rates were equivalent (167). None of the various drilling techniques appears to offer obvious advantages (166). The results of the ovarian drilling may in some cases also be temporary...


A 40-year-old Hispanic female with polycystic ovaries, who has had diabetes for 2 years, is taking 120 mg of nateglinide three times a day and 45 mg of pioglitazone once daily, with an A1-C of 6 , postprandial glucoses of 130-140, and fasting glucoses of 100-110 presents with a positive urine and blood pregnancy test 10 days after her expected menstrual period. Patients with polycystic ovary syndrome can ovulate and become pregnant when placed on TZD therapy. Because oral agents are contraindicated during pregnancy, both oral agents should be stopped and the patient placed on insulin. Clinical trials have shown that close monitoring of pregnant diabetic patients with postprandial glucose was superior to monitoring with fasting glucose, with better A1-C control and less fetal and neonatal complications. Although analog insulins have been studied in pregnancy, they are not currently approved for this use, therefore postprandial glucose monitoring with administration of human regular...

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