Women with unusual hair growth, irregular or absent periods, and ovaries that appear large and shiny when viewed with ultrasound often have one thing in common: They are diagnosed with polycystic ovary syndrome, also known as PCOS. Acupuncturists frequently encounter patients with PCOS who seek our help with overweight, hirsutism, irregular menstrual cycles, infertility, and a range of other health concerns. Chinese medicine has been addressing these signs and symptoms for hundreds of years, and we can offer relieve to women with PCOS and help them balance and improve their health.
In this article I will describe PCOS as it is currently defined in conventional medicine. I will explain diagnostic parameters, medical treatments and their side-effects, and the long-term outlook for women diagnosed with PCOS. We will then look at patients with signs and symptoms of PCOS through a Chinese medicine lens, exploring etiology, patterns of disharmony, and treatment strategies using acupuncture and Chinese herbal prescription. The last part of this article will draw attention to additional strategies based in naturopathic medicine and nutrition, which can be integrated with biomedical and Chinese medical approaches. These can serve as a bridge to other personal practices such as meditation, qigong, and yoga.
Polycystic Ovary Syndrome, a Biomedical Diagnosis
PCOS is a common heterogenous endocrine disorder that affects about five million women of reproductive age in the United States. Genetic, epigenetic as well as environmental factors contribute to the development of this syndrome. Diagnostic criteria are not uniform, so the statistical range is rather wide. Usually, women with oligo- or amenorrhea, elevated androgen levels and polycystic ovaries are considered to have the syndrome. They manifest with any combination of the following signs and symptoms: excess hair growth, alopecia, skin discoloration, acne, anovulation, infrequent, absent or heavy periods, a fact that is often connected to difficulty conceiving or carrying pregnancy to term, and weight gain. In addition, women with PCOS have a higher lifetime risk of insulin resistance, metabolic syndrome, Type 2 diabetes, obesity, cardiovascular disease, dyslipidemia, sleep apnea, and inflammation that may lead to atherosclerosis. Women with PCOS are about three times more likely to develop endometrial carcinoma than women without the syndrome. Many also experience mood disorders such as depression. Polycystic ovary syndrome is considered incurable, but medical treatments to manage the syndrome are available and helpful in many cases to alleviate symptoms and to allow women with PCOS to have children.
Because the etiology and pathomechanism of PCOS are incompletely understood, medical treatment is primarily targeting symptoms rather than underlying mechanisms. Even modest weight loss of 10-15% in overweight women with PCOS can reduce androgen levels as well as improve ovulation and insulin sensitivity. Pharmaceutical treatments include combination hormonal birth control to regulate the menstrual cycle. Metformin reduces androgen levels but does not much improve fertility or insulin action. However, several clinical trials have put its effectiveness in women with PCOS in question. In addition, many women experience serious gastro-intestinal and other side-effects. Clomiphene (or sometimes clomiphene in combination with metformin) is recommended to women attempting to fall pregnant, but multiple pregnancy is not uncommon. These drugs do not address the psychosocial aspects of PCOS. Less frequently used is gonadotropin stimulation, which can temporarily improve ovarian function but may also lead to potentially fatal ovarian hyperstimulation syndrome. Multiple ovarian cysts can be reduced surgically (“ovarian drilling”), but the effect is transient. IVF is a commonly recommended path to pregnancy for women who do not fall pregnant with medical management alone. Little is known whether screening and subsequent treatment can reduce morbidity and mortality in women with PCOS.
Menstrual Difficulties in Chinese Medicine
Gynecology is a prominent subspecialty of Chinese medicine. Chinese gynecologists focus on the treatment with herbal prescription, but acupuncture also plays an important role and has been shown in clinical studies to be useful in the regulation of endocrine disorders, including PCOS. Polycystic ovary syndrome is a modern biomedical concept, but Chinese medicine has documented several diseases and patterns of disharmony for hundreds of years that closely resemble the presentations of PCOS, briefly explained below.
Chinese medicine uses a different paradigm and its own terminology to describe normal and abnormal physiology. Fertility centers around the concepts of Kidney Jing and Tian Gui, which support and regulate all essential aspects of reproductive function, particularly the functioning of the Chong and Ren Mai, two of the Extraordinary Vessels. If periods are absent or infrequent, these two vessels are not functioning optimally. Both can be affected by imbalances in Liver Qi. When weight gain, esp. around the waist, is involved, dysfunction of the Dai Mai and Phlegm-Damp accumulation are part of the pathomechanism. This points to a weak Spleen function that needs support through herbal treatment and lifestyle changes such as diet and movement. Other signs of hyperandrogenism manifesting as hirsutism, alopecia, acne, or skin discoloration are due to Damp-Heat or Phlegm-Damp, depending on the source text. Cardiovascular involvement is a reflection of Blood Stasis. Thus, an analysis of the various presentations of PCOS according to Chinese medicine may include any of the following factors, often in some combination: dysfunction of the Chong and Ren Mai, or of the Dai Mai, Dampness, Phlegm-Damp accumulation, Damp-Heat, Blood Stasis, Kidney Jing deficiency. Common to all of them is improper functioning of Liver and Spleen Qi.
Once we have established the precise pattern diagnosis for our patient according to Chinese medicine, developing the appropriate herbal treatment strategy is usually fairly straight-forward and rational. Herbs used in these prescriptions focus on resolving Damp, guiding out Phlegm, boosting Yang, tonifying Qi, and, more generally, nourishing Jing. Any of these formulas should be balanced with appropriate Qi and Blood regulating herbs, as well as Kidney Yin and Blood nourishing herbs when needed.
Acupuncture in the treatment of PCOS manifestations is more varied than Chinese herbal medicine, depending on the philosophical underpinnings of the approach. Conventional TCM-style acupuncture attempts to apply Zangfu diagnostic and treatment principles to individual acupuncture point actions and indications. Other styles, such as meridian, Five Element, Japanese and other classical approaches, aim to restore energetic balance rooted more in an understanding of channel pathology. Modern clinical studies have demonstrated the beneficial effects of electroacupuncture on several biomarkers representative of PCOS-related endocrine imbalances as well as improving ovulation and conception in women with PCOS-related menstrual irregularities.
Additional Naturopathic Strategies
Three areas that fall more appropriately under the domain of naturopathic medicine are Western phytotherapy, nutritional supplements, and dietary approaches.
Several clinical studies in the last few years evaluated black cohosh (Cimicifuga racemosa), Maitake mushroom (Grifola frondosa) and chaste tree (Vitex agnus-castus) for their effects on relevant biomarkers and achieved pregnancies compared to pharmaceutical treatments. The outcomes were very encouraging and warrant further study.
Nutritional supplementation is a natural area of investigation in metabolic and endocrine disorders such as diabetes and PCOS. Of particular interest are two forms of the carbohydrate molecule inositol: myo-inositol and D-chiro-inositol. In the ovaries, myo-inositol regulates glucose uptake and FSH signaling. D-chiro-inositol, on the other hand, is involved in insulin-mediated androgen production. Most recent investigations and discussions focus on the proper ratio of these two isomers. D-chiro-inositol is less readily available through nutrition than myo-inositol but has shown beneficial effects on several biomarker in studies of women with PCOS.
A cornerstone of healing for most women successfully managing PCOS is a strategic movement away from the standard American diet. Most nutritional recommendations lean towards more traditional, whole-foods approaches reminiscent of modified paleo/mediterranean diets. I have observed profound and positive changes in my patients who have moved away from a carbohydrate-dominated diet to a more balanced approach emphasizing more high-quality fats and proteins. The most benefits have accrued to those who started cooking at home again. Aside from providing more nutritious meals, just reducing the intake of simple carbohydrates can help women with PCOS manage fluctuations in blood glucose levels that can be detrimental for anyone with metabolic imbalances.
In East Asian medicine we are naturally inclined to encourage practices such as meditation, taichi/qigong and yoga because they are excellent strategies to manage the impact of stress and cultivate self-awareness. Women with PCOS have been shown in numerous studies to be less resilient, so stress management is even more critical for their health. Indian researchers have documented the benefits of yoga in women with PCOS (Nidhi et al. 2013). Though clinical studies of mindfulness meditation and taichi/qigong specific to women with PCOS are scant, their potential side-effects are low, so women should be encouraged to try and implement any one or several of these according to their personal inclinations and preferences.
A Multi-faceted Approach Is Needed
PCOS is a complex condition that manifests differently in individual women. It can have a serious impact on a woman’s fertility, self-image, longevity and general health. Conventional biomedicine does not currently offer a comprehensive, successful strategy to management, not to mention a cure. A multi-disciplinary holistic approach is thus appropriate to help women regain a sense of control over their health. It is important to remember that both pharmaceutical and herbal interventions have a potential for side-effects, especially if used long-term, which should be carefully studied and monitored. Nutritional and lifestyle changes play a significant role in reducing symptoms and improving overall health. They can instill a sense of empowerment in women with PCOS and should thus be emphasized and encouraged.
© 2022 Christiane Siebert