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ATURAL
EDICINE 101
by Jeffrey Dach MD
Buy Book
PCOS Polycystic
Ovary Syndrome
- Anovulatory Androgen Excess
by Jeffrey Dach MD
This article is Part One of a series,
For Part Two, Click Here.
Seventeen year old Alice has PCOS (Polycystic Ovary Syndrome). Alice came
with her Mom into the office and told me her story. Alice has been overweight,
borderline diabetic, and has facial hair and acne caused by elevated testosterone. At
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age 12, Alice started normal menstrual cycles, but her cycles began fluctuating and
periods stopped at age 15. Her gyne doctor diagnosed PCOS (Polycystic Ovary
Syndrome), and put her on birth control pills to regulate her cycles. The birth control
pills caused adverse side effects of weight gain weight and elevated blood pressure
(hypertension), so she stopped them.
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(no ovulation)
Weight gain, obesity, Hirsutism (excessive hair growth, male
pattern)
Insulin resistance (pre-diabetes), Acne, Male-pattern
baldness, Multiple small ovarian cysts on sonogram,
Acanthosis Nigrans (darkening of the skin at the nape of the
neck and under arms)-indicator of hyperinsulinemia
Above Left Image: Obese Young Lady with PCOS, anovulatory infertility, acne and facial hair.
Definition of Anovulation: The egg doesn'tt pop out and there is no progesterone
production. The cycles are irregular or absent.
Above Left Image: Typical hirsutism, with hair growth under the chin.
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are becoming balanced, but to see these results, you'll need to give the treatment at
least six months, in conjunction with proper diet and exercise." This is quoted
from the The John R Lee Medical Letter 1999.(10)
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Ultrasound
of PCOS
JLML: How do you track your luteal phase with a basal temperature
chart?
JCPrior: If you record your oral temperature every morning for an entire
month using a digital thermometer, record the temperature in the
evening before you go to bed, and record any illness or early or late
rising, you can quantitatively determine which days of the cycle are high
progesterone days. You can then take all of those daily temperatures
from the beginning of one period until the day before the beginning of
the next, and do an average of the temperatures. The point where your
temperature goes above that average, and stays above it, is the
beginning of the luteal phase. It will go back down when your period
starts or just before. That's how easy it is to figure out your luteal phase
length! That alone is valuable information for women who are having
miscarriages that may be due to a short luteal phase.
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JLML: I have found that women who are more aware of their cycles are
often better able to self-treat for hormone imbalances.
JLML: What else can you tell us about anovulatory cycles? The other kind
of ovulation disturbance I called turned on. The woman experiencing
this kind of ovulation disturbance will complain of weight gain, acne, and
hair where she doesnt want it. The biology of this is less clear, but it
relates to insulin excess and insulin resistance, which have effects both
on the brain by increasing LH (luteinizing hormone) levels, and directly
on the ovary. Excess insulin sits on receptors on the theca cells, the
outer coat of the ovary, and makes them more responsive to the
hormonal environment, and therefore they make more androgens
[testosterone, male hormones].
JLML: Aha! So that's why a high sugar diet aggravates polycystic ovary
syndrome. The excess sugar creates high insulin levels, which stimulate
androgen production in the ovary, which suppresses ovulation.
JCPrior: The higher LH and the higher androgen levels set up a signal
that inhibits the follicle from ovulating. Because each follicle grows and
creates a lake of fluid around it, if it doesnt burst and release its egg, a
cyst is left. Therefore you get into a situation of high or normal estrogen
levels, high androgens, and low progesterone. That condition is usually
characterized by obesity, especially middle-of-the-body obesity,
androgen signs such acne, oily skin, facial and breast hair, and head hair
loss. Because estrogen tends to be higher with weight gain, these are the
women who have a higher breast cancer and endometrial cancer risk.
They may also have the worst PMS symptoms.
JLML: So this is yet another good reason to avoid sugar and refined
carbohydrates such as white bread and pasta.
JCPrior: And it's another good reason to get plenty of aerobic or
endurance-type exercise, which is one of the best ways of getting the
insulin levels down and decreasing PMS. With turned on ovulation
disturbances you need to correct three problems: The first is to bring
progesterone into balance and for this you use physiologic doses of
progesterone. Next, you often you need to block the effect of the male
hormone. There's a medicine called spironolactone which I use that
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blocks androgen action at the cell level. Finally, if a person has a family
history of diabetes or is quite obese, then I may use a drug called
metformin (Glucophage) that sensitizes the body to insulin and allows
the insulin levels to go down.
JLML: I have found that supplemental progesterone, a good amount of
exercise, and a low sugar diet, low simple carbohydrate and low fat
diet with plenty of vegetables will often restore balance.
The above interview posted courtesy of Virginia Hopkins Health Watch. (4)
I use cyclic progesterone therapy as the heart of treatment for PCOSanovulatory androgen excess.(6) Progesterone is the hormone made by
the ovary after an egg is released.
The fundamental problem with PCOS is not making progesterone for two
weeks every cycle. This lack of progesterone leads to an imbalance in the
ovary, causes the stimulation of higher male hormones and leads to the
irregular periods and trouble getting pregnant. Progesterone is usually
missingreplacing it therefore makes sense. Progesterone talks back to
the hypothalamic and pituitary (brain) hormones that control the ovary,
and stops them from stimulating the ovary to make too much
testosterone.
Taking progesterone for two weeks every month (called cyclic
progesterone) may help the brain to develop the normal cyclic rhythm
that is missing in PCOS. Progesterone also counterbalances the steadily
high estrogen levels that the PCOS ovary produces even if you have no
periods. Progesterone will prevent estrogen over-stimulation of the
uterine lining (endometrial hyperplasia) and heavy flow. It may also
interfere with the action of high estrogen on the breasts, therefore
preventing tenderness and lumpiness and perhaps even the risk for
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breast cancer.
Finally, and most doctors dont realize this, progesterone antagonizes
and inhibits the enzyme (called 5-alpha reductase) that is needed to
make testosterone into dihydrotestosterone. Dihydrotestosterone is the
powerful male hormone that talks hair follicles into making coarse hair
and too much oil that causes acne.
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_________________________________________________________
Drug Treatment
Infertility, anovulation:
Clomid clomephine, induces ovulation.
Insulin Resistance:
Metformin improves insulin sensitivity.(39)(39A)
Acne, Facial Hair:
Spironlactone, Aldactone inhibits testosterone.
__________________________________________________________
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Prolactin
TSH
17-hydroxyprogesterone to rule out 21-hydroxylase deficiency (CAH).
Fasting insulin level or GTT with insulin levels (also called IGTT).
Fasting Glucose to Fasting Insulin ratio <4.5 is cheaper method
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REFERENCES
(1) http://www.amazon.com/Clinical-Gynecologic-Endocrinology-Infertility-Editorial
/dp/0781747953
The Clinical Gynecologic Endocrinology and Infertility: Leon Speroff MD
(2) http://jcem.endojournals.org/cgi/content/full/88/5/1927
A Modern Medical Quandary: Polycystic Ovary Syndrome, Insulin Resistance, and
Oral Contraceptive Pills, The Journal of Clinical Endocrinology & Metabolism Vol. 88,
No. 5 1927-1932
(3) http://www.pcosupport.org/newsletter/articles/article122707-3.php
Can PCOS be Treated with Natural Progesterone? Jerilynn Prior, PCOSA Today
Newsletter
(4) http://www.virginiahopkinstestkits.com/priorovaries.html
WHAT MAKES YOUR OVARIES TICK, Insights about ovulation, fertility, PCOS and
more.An Interview with Jerilynn C. Prior, M.D. FRCPC
(5) http://www.cemcor.ubc.ca/help_yourself/articles/challenge_pcos
Help for Anovulatory Androgen Excess (AAE)Challenge PCOS! by Dr. Jerilynn C.
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http://www.natural-progesterone-advisory-network.com/
what-is-the-guidelines-to-progesterone-dosage/
http://search.yahoo.com/
search?p=pcos+message+board&fr=yfp-t-501-s&toggle=1&cop=mss&ei=UTF-8
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Birth Control Pill Side effects. Oral contraceptive pill may prevent more than
pregnancy
New research indicates birth control pill could cause long-term problems with
testosterone
(20) http://ditchthepill.org/
Ditch the Pill . org, very neative about BCPs
Jones, M.D. Medical Director, Womens Health Institute
THYROID References
(21) http://www.ncbi.nlm.nih.gov/pubmed/16208308?dopt
Abstract Minerva Endocrinol. 2005 Sep;30(3):193-7. Relationship between insulin
secretion, and thyroid and ovary function in patients suffering from polycystic ovary.
CONCLUSIONS: The data obtained in our study enable us to support the close
connection between ovary function, thyroid function and insulin-resistance. In all
patients, in fact, albeit at different times, an improvement was obtained in all 3
pathologies.
(22) http://www.ncbi.nlm.nih.gov/pubmed/17302862
Thyroid disease and female reproduction. Poppe K, Velkeniers B, Glinoer D. Clin
Endocrinol (Oxf). 2007 Mar;66(3):309-21
(23) http://www.ncbi.nlm.nih.gov/pubmed/15012623
High prevalence of autoimmune thyroiditis in patients with polycystic ovary
syndrome.Janssen OE. Eur J Endocrinol. 2004 Mar;150(3):363-9. CONCLUSION:
This prospective study demonstrates a threefold higher prevalence of Autoimmune
Thyroid disorders in patients with PCOS
Prevalence of PCOS in Population
(24) http://jcem.endojournals.org/cgi/content/full/85/7/2434
A Prospective Study of the Prevalence of the Polycystic Ovary Syndrome in
Unselected Caucasian Women from Spain. Our results demonstrate a 6.5%
prevalence of PCOS, as defined, in a minimally biased population of Caucasian
women from Spain. The polycystic ovary syndrome, hirsutism, and acne are common
endocrine disorders in women. The Journal of Clinical Endocrinology & Metabolism
Vol. 85, No. 7 2434-2438
Thyroid References
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(25) http://www.ncbi.nlm.nih.gov/pubmed/8053991
Hypothyroidism presenting with polycystic ovary syndrome.Sridhar GR. J Assoc
Physicians India. 1993 Feb;41(2):88-90. During a 30 months period, two women of
primary hypothyroidism (2/13; 1.04%) presented with features of polycystic ovary
syndrome (PCOS). In hypothyroidism, sex hormone binding globulin levels are
decreased; increased conversion of androstenedione to testosterone, and
aromatization to estradiol are present, all these being an exaggeration of
biochemical changes characteristic of PCOS. Besides, metabolic clearance rates of
androstenedione and estrone, the putative mediators of PCOS, are reduced.
Hypothyroidism can either initiate, maintain or worsen the syndrome. Correction of
hypothyroidism when present, would therefore form an important aspect in the
management of infertility associated with PCOS.
(26) http://www.ncbi.nlm.nih.gov/pubmed/17954423
Precocious puberty and large multicystic ovaries in young girls with primary
hypothyroidism.Sanjeevaiah AR, Sanjay S, Deepak T, Sharada A, Srikanta SS.
Samatvam Endocrinology Diabetes Center, Bangalore, India.
(27) http://www.ncbi.nlm.nih.gov/pubmed/17917634
Mymensingh Med J. 2007 Jul;16(2 Suppl):S60-62. Vaginal bleeding with multicystic
ovaries and a pituitary mass in a child with severe hypothyroidism.Mohsin F, Nahar
N, Azad K, Nahar J. Department of Paediatrics, Bangladesh Institute of Research and
Rehabilitation on Diabetes, Endocrine and Metabolic Disorders (BIRDEM), Dhaka,
Bangladesh.
A seven year and ten months old girl presented with cyclic vaginal bleeding and a
huge abdominopelvic mass. She had clinical features of hypothyroidism. The
investigation results were consistent with the diagnosis of primary hypothyroidism
with precocious puberty. She also had bilaterally enlarged cystic ovaries on CT scan
of abdomen and CT scan of brain showed pituitary macroadenoma. After starting
treatment with thyroxine, patient became euthyroid and her general condition
improved. Treatment with thyroxine alone halted the cyclic vaginal bleeding, led to
rapid resolution of the ovarian cysts and regression of the pituitary mass.
(28) http://www.ncbi.nlm.nih.gov/pubmed/2729396
Spontaneous ovarian hyperstimulation syndrome associated with hypothyroidism.
Rotmensch S, Scommegna A. Department of Obstetrics and Gynecology, Michael
Reese Hospital and Medical Center, University of Chicago, Pritzker School of
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http://www.ncbi.nlm.nih.gov/pubmed/17954423?ordinalpos=4&
itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
Precocious puberty and large multicystic ovaries in young girls with primary
hypothyroidism.Sanjeevaiah AR, Sanjay S, Deepak T, Sharada A, Srikanta SS.
Endocr Pract. 2007 Oct;13(6):652-5.
(30) http://www.ncbi.nlm.nih.gov/pubmed/16864150
Primary hypothyroidism presenting as ovarian tumor and precocious puberty in a
prepubertal girl.Campaner AB, Scapinelli A, Machado RO, Dos Santos RE, Beznos
GW, Aoki T. Department of Obstetrics and Gynecology, Santa Casa So Paulo-Faculty
of Medical Science, So Paulo, Brazil. Gynecol Endocrinol. 2006 Jul;22(7):395-8.
We report a case of a prepubertal girl with juvenile primary hypothyroidism
presenting as ovarian cysts and precocious puberty. The 7-year-old female was
referred to our clinic because of a pelvic/abdominal mass and vaginal bleeding.
Besides these findings, on physical examination we noticed the thyroid gland globally
increased and the presence of secondary sexual characteristics. Based upon the
clinical profile and investigations, the patient was diagnosed with juvenile primary
hypothyroidism due to autoimmune thyroiditis. The cysts and precocious puberty
resolved spontaneously after the simple replacement of thyroid hormone. It is
important to bear in mind hypothyroidism in cases of girls presenting ovarian cysts
and precocious puberty in order to avoid unnecessary surgery on the ovaries.
(31) http://www.ncbi.nlm.nih.gov/pubmed/16995569
J Pediatr Endocrinol Metab. 2006 Jul;19(7):895-900.
Ovarian cysts in young girls with hypothyroidism: follow-up and effect of
treatment.Sharma Y, Bajpai A, Mittal S, Ovarian cysts have been reported in girls
with longstanding uncompensated primary hypothyroidism. Restoration of euthyroid
state has been associated with resolution of these cysts; long-term follow-up of these
patients is however lacking. Our study emphasizes the need to exclude
hypothyroidism in young girls with ovarian cysts. A causal link between
hypothyroidism and spontaneously occurring ovarian hyperstimulation syndrome is
suggested by analysis of data from a patient with myxedema and review of data from
animal research.
(32) http://www.jacemedical.com/articles
/Sub-laboratory%20Hypothyroidism%20.pdf
Sub-laboratory Hypothyroidism and the Empirical use of Armour Thyroid Alan R.
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dihydroxyvitamin D <5 pg/ml (nl: 15-60). The mean intact parathyroid hormone
level was 47 +/- 19 pg/ml (nl: 10-65), with five women with abnormally elevated
parathyroid hormone levels. All were normocalcemic (9.3 +/- 0.4 mg/dl).
Vitamin D repletion with calcium therapy resulted in normalized menstrual
cycles within 2 months for seven women, with two experiencing resolution of
their dysfunctional bleeding. Two became pregnant, and the other four patients
maintained normal menstrual cycles. These data suggest that abnormalities in
calcium homeostasis may be responsible, in part, for the arrested follicular
development in women with PCO and may contribute to the pathogenesis of PCO.
METFORMIN
(39) http://content.nejm.org/cgi/content/extract/358/1/47
Metformin for the Treatment of the Polycystic Ovary Syndrome John E. Nestler, M.D.
N. Engl. J. Med., January 3, 2008; 358(1): 47 - 54.
(39A) http://www.ovarian-cysts-pcos.com/glucophage-metformin-pcos.html
PCOS and Metformin (Glucophage)
Diet and Weight Loss
(40) http://www.ovarian-cysts-pcos.com/pcos-book-res.html
The Natural Diet Solution for PCOS and Infertility Nancy Dunne, ND Bill Slater, MBA
(41) http://www.ovarian-cysts-pcos.com/PCOS-success.html#sec1
PCOS success stories by Nancy Dunne
Conventional Medical Diagnosis and Treatment of PCOS
(42) http://www.amazon.com/Clinical-Gynecologic-Endocrinology-Infertility-Editorial/dp/0781747953
Speroff on PCOS: Clinical Gynecologic Endocrinology and Infertility by Leon Speroff
MD p.493
A question which has puzzled gynecologists and endocrinologists for many years is
what causes polycystic ovaries. There is an answer which is appealing in its logic and
clinical applicability. The characteristic polycystic ovary emerges when a state of
anovulation persists for any length of time Should you have a sonogram to make
the diagnosis of PCOS? From 8-14% of normal women will demonstrate
ultrasonographic findings typical of polycystic ovaries. Ultrasonography as a
diagnostic tool for this condition is unnecessary, and we vigorously discourage its use
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(49) http://www.inciid.org/printpage.php?cat=pcos&id=505
Understanding and managing Polycystic Ovarian Syndrome (PCOS) by Sam Thatcher,
M.D., Ph.D. director of the Center for Applied Reproductive Science in Johnson City,
TN,. Conventional Approach.
(50) http://www.perspectivespress.com/0-944934-25-0.html
PCOS: The Hidden Epidemic. a Book by Sam Thatcher MD
PhD, Conventional Approach to PCOS.
(51) http://www.emedicine.com/ped/topic2155.htm
Polycystic Ovarian Syndrome Last Updated: September 15, 2006, on E-Medicine.
(52) http://www.endotext.org/female/female6/female6.htm
ENDOTEXT.COM, HYPERANDROGENISM, HIRSUTISM AND POLYCYSTIC OVARY
SYNDROMEChapter 6 - Randall B. Barnes, M.D., Adrienne B. Neithardt, M.D. and
Suleena K. Kalra, M.D.November 19, 2003 on Endotext.com
(53) http://jcem.endojournals.org/cgi/content/full/89/2/453
EXTENSIVE PERSONAL EXPERIENCE Androgen Excess in Women: Experience with
Over 1000 Consecutive Patients R. AZZIZ, L. A. SANCHEZ, E. S. KNOCHENHAUER,
C. MORAN, J. LAZENBY, K. C. STEPHENS,K. TAYLOR, AND L. R. BOOTS The Journal
of Clinical Endocrinology & Metabolism 89(2):453462. All patients with menstrual
or ovulatory dysfunction received BCPs' (OCs) when possible. Patients with unwanted
hair growth and evidence of excess facial or body terminal hair growth received
spironolactone (SPA) (200 mg ; 100 mg/d) in combination with the OC, to minimize
the risks of teratogenicity. SPA was rarely used alone, except in the occasional
hirsute patient who had previously undergone a hysterectomy or tubal ligation.
Other treatment regimens were occasionally used, including glucocorticoids, insulin
sensitizers, GnRH analogs, flutamide, finasteride, and other estrogen-progestin
combinations, alone or in combination; the majority of these were used as part of
clinical trials (2426).
(54) http://www.joplink.net/prev/200201/ref/01-02.html
Stein IF, Leventhal ML. Amenorrhoea associated with bilateral polycystic ovaries. Am
J Obstet Gynecol 1935;29:18191.
The Environment, Endocrine Disruptor Chemicals and PCOS
(55) http://www.ourstolenfuture.org/Consensus/2005/2005-1030vallombrosa.htm
Vallombrosa Consensus Statement on Environmental contaminants and human
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fertility compromise.
October 2005.
(56) http://www.ourstolenfuture.org/index.htm
Our Stolen Future, endocrine disruptors in the environment
(57) http://www.ovarian-cysts-pcos.com/news13-pcos-pesticides.html#sec1
Pesticides and PCOS
(58) http://humupd.oxfordjournals.org/cgi/reprint/7/3/323.pdf
Endocrine Disruptors as environmental cause of PCOSThe impact of Endocrine
Disruptors on the Female Reproductive System, Stamati and pitsos et al.
Testosterone for Women
(59) http://www.asrm.org/Literature/Menopausal_Medicine/menomedsummer01.pdf
Testosterone Treatment: Psychological and Physical Effects in Postmenopausal
Women.
Susan R. Davis, M.B.B.S., F.R.A.C.P., Ph.D. Menopausal Volume 9, Number 2,
Summer 2001
Diet for PCOS
(61) http://pcos.is/files/pcosbook1.pdf
A complete online book on Diet and Nutrition for PCOS by Nancy Dunn
(62) http://www.topfitonline.com/chartglycemic.htm
Glycemic Index Chart - handy and useful.
Questionnaire for PCOS
(63) http://www.cfp.ca/cgi/content/full/53/6/1041/T50531041
Table 5 Clinical tool for diagnosis of polycystic ovary syndrome
Can Fam Physician Vol. 53, No. 6, June 2007, pp.1041 - 1047 , Polycystic ovary
syndrome. Validated questionnaire for use in diagnosis, Sue D. Pedersen, et al.
(64) http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&
artid=1949220
Can Fam Physician. 2007 June; 53(6): 10411047. Polycystic ovary syndrome.
Validated questionnaire for use in diagnosis, Sue D. Pedersen, et al.
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(65)http://www.acamnet.org/site/c.ltJWJ4MPIwE/b.2242497/k.2C78/Integrative_Medicine_
Physicians/apps/kb/cs/contactsearch.asp
http://jeffreydach.com/2008/02/27/a-commonly-missed-cause-of-infertility-nonclassical-cah-by-jeffrey-
dach-md.aspx
MD
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disclaimer http://www.drdach.com/wst_page20.html
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