Whole Health Library

Reprinted with permission from Elsevier Copyright 2012

PCOS results from various endocrine and metabolic abnormalities, including hypothalamic-pituitary dysfunction, abnormal ovarian hormone production, and hyperinsulinemia. These imbalances perpetuate a sequence of elevated testosterone, abnormal estrogen to progesterone ratio, insulin resistance, and dysregulation of the hypothalamic-pituitary feedback system.[2]

Treatment of PCOS is directed at decreasing insulin resistance, reducing hyperandrogenism, managing diabetes and cardiac disease if present, and addressing fertility concerns. Lifestyle modifications should be emphasized to improve insulin sensitivity and promote weight loss. Conventional approaches include insulin sensitizers such as metformin, oral contraceptive pills with low androgenic activity, progestins for endometrial protection, and antiandrogens for symptoms of hirsutism. [5] However, a comprehensive approach that considers a woman’s overall health is important, as the syndrome of PCOS indicates underlying systemic imbalances that need to be addressed.

Moving the Body

Regular, moderate physical activity should be encouraged in all women with PCOS. Evidence shows that regular exercise helps to promote weight loss, improving ovulation and insulin resistance.[5] Even a 5% loss of initial body weight can result in significant improvements in metabolic and hormonal balance, especially in women with a BMI greater than 30.[6]

Food and Drink

To address insulin resistance, a low-carbohydrate, low-glycemic index, high-fiber diet should be encouraged.[2] Appropriate dietary guidelines include the anti-inflammatory diet or the Mediterranean diet; both limit intake of processed foods, red meat, and dairy high in saturated fat. More information is available in the “Food and Drink” Whole Health overview.

Power of the Mind

Women with PCOS have increased sympathetic nervous system activity, often in addition to anxiety and depression.[2] For this reason, mind-body interventions to address stress management and teach relaxation and breathing exercises can improve heart rate variability and decrease sympathetic tone[7]; for more information reviews the “Heart Rate Variability and Arrhythmias” Whole Health tool. A few small studies have shown that women with PCOS receiving acupuncture had increased rates of ovulation and decreased sympathetic tone.[8] Although women with PCOS may benefit from additional mind-body techniques and complementary modalities, at this time little research exists to document their efficacy.

There are multiple supplements with proposed benefit in PCOS, addressing both insulin resistance and hyperandrogenism. Although the evidence varies for each of these products, they may be helpful as part of a holistic approach to the treatment of PCOS.

Vitamin D regulates insulin secretion. Lower levels may be associated with higher BMI and insulin resistance. Meta-analysis of 11 trials demonstrated that vitamin D supplementation in women with PCOS may improve insulin sensitivity. Consider supplementing to 2,000 units daily, or higher doses if indicated by serum 25-OH vitamin D levels.[9]

Inositol mediates insulin activity in the body. Supplementation with D-chiro-inositol (DCI) has been shown to improve insulin sensitivity and ovulation, decrease triglyceride and testosterone levels, and support weight loss.[2] D-pinitol, more accessible commercially, increases serum levels of DCI and decreases glucose levels, although research findings are mixed. The suggested dose of both DCI and pinitol is 600 mg twice daily. Both are generally well tolerated.[10]

Chromium is a mineral that improves insulin function and decreases blood glucose levels. A meta-analysis of 7 trials found that chromium supplementation improved BMI, free testosterone, and fasting insulin in PCOS. [11] The FDA reports that chromium can be used safely in doses of 200 mcg daily for up to 6 months; in many studies, 1,000 mcg daily has been used safely. There is insufficient information, however, to comment on safety in long-term use. The suggested dose is 200 to 1,000 mcg of chromium picolinate in divided doses daily. Interactions with medications can occur, especially with thyroid hormone. Side effects include headache, sleep disturbances, and mood issues. Avoid chromium in people with kidney disease.[12]

N-acetylcysteine (NAC) is a precursor to glutathione, a powerful antioxidant. It is used in many conditions, and some evidence supports its use in improving insulin sensitivity and decreasing inflammation.[2] The suggested dose is 1,200 to 1,800 mg daily in divided doses. NAC generally is well tolerated, with occasional nausea reported.

Licorice (glycyrrhiza glabra) has antiandrogenic effects. It can be taken alone, and it also works well with spironolactone to counter its side effects of hyperkalemia and low blood pressure. The suggested dose is 500 mg standardized to 6%-15% glycrrhizin. Due to its mineralocorticoid properties, short-term and closely monitored use is recommended. Toxicities include hypokalemia, hypertension, and fluid retention.[13]

Additional supplements and herbs have glucose-lowering effects, and their use should be considered in the treatment of PCOS. For more information and additional suggestions, refer to the “Endocrine Health” Whole Health overview.

Through the process of completing her personal health inventory, Julie realized that her school and work responsibilities dominated her life and that she was not making time for herself. She saw that eating unhealthily and not exercising resulted in weight gain that perpetuated insulin resistance. She appreciated the relationship between not sleeping enough and her worsening mood and concentration difficulties. She acknowledged that she was spending little time participating in activities and interacting with people that she enjoyed. Her choices were negatively impacting her own health.

With this new awareness, Julie committed to changing her lifestyle to prioritize her health. She began by packing her own lunches, limiting eating out to twice weekly, and swapping out fruits and vegetables in place of high-carbohydrate, high-glycemic index snacks. She started walking to classes instead of taking the bus and walked her dog outside for at least 30 minutes three times a week. To help improve her insulin sensitivity, she decided to try inositol. To help with contraception, Julie started taking an oral contraceptive pill with low androgenic activity, and her periods became regular. She committed to sleeping at least seven hours a night and as a result found it easier to concentrate on work during the day. She set a goal of scheduling at least one social interaction with friends or family each week. Julie met once with a health psychologist who reviewed mind-body techniques for stress reduction that she could use and practice on her own.

Years later at the age of 49, Julie returns to the clinic. She has remained committed to a healthy lifestyle over the years, exercising for 30-45 minutes at least three times a week at her local gym. She eats a diet with moderate fruits and vegetables, and through her efforts has maintained a normal body weight. She has three children and a supportive husband; she is an elementary school teacher.

Julie presents with menopausal symptoms. Her periods have become irregular, often skipping months. She experiences troublesome hot flashes that interfere with work and sleep. Pain from vaginal dryness has caused less frequent sexual intercourse, straining her relationship with her husband. Although she has heard of hormone replacement therapy, Julie is interested in trying other, more “natural” approaches. She is interested in overall recommendations to keep her healthy as she approaches her 50th birthday.

Personal Health Inventory

Julie rates herself a 4 out of 5 for her overall physical well-being and a 3 for overall mental and emotional well-being. When asked what matters most to her and why she wants to be healthy, Julie responds:

“Raising healthy, well-balanced children with a sense of value and responsibility. Continuing to grow in my relationship with my husband and spending time with my family. Finding ways to help others and give back.”

For the eight areas of self-care, Julie rates herself on where she is, and where she would like to be. Julie decides to first focus on the areas of Recharge and Spirit and Soul by learning more about bioidentical hormones and becoming more active in her church.

For more information, refer to Julie’s PHI.

Menopause is the cessation of menstrual cycles, occurring for most women between the ages of 47 and 55 years. During perimenopause, as estrogen levels decrease, women often experience hot flashes, night sweats, vaginal dryness, and mood swings. While some women experience debilitating symptoms, others transition through this time with few complaints. Unless precipitated by surgery or illness, menopause is part of the natural aging process. As such, remind women to consider this time as an opportunity to celebrate their beauty, strength, and vitality by recommitting to a healthy lifestyle.

Controversy exists regarding the practice of measuring hormone levels for the diagnosis, treatment, and monitoring of menopause and its symptoms. Testing may not be reliable depending on the source (serum, saliva, or urine) and the method of hormone replacement administration. Because of the lack of research, routine testing is likely unnecessary for most women.[14] The diagnosis of menopause should be made based on clinical findings; treatment is based on symptoms.

Before addressing specific symptoms, clinicians should review the importance of a comprehensive approach to wellness during the menopausal transition. Cardiac and bone health should be addressed because of the increased risk of coronary artery disease and osteoporosis.

Moving the Body

Regular exercise has significant benefits for overall health and well-being. Exercise should include muscle strengthening, weight-bearing activities, and yoga or tai chi to strengthen the mind-body connection. A Cochrane review in 2011 found that non-weight bearing, high-force activities such as progressive resistance strength training was most effective in increasing femur neck bone density,[15] whereas combinations of aerobic activity, weight-bearing, and resistance exercises improved bone density of the spine.

A 2007 Cochrane review concluded the evidence was insufficient to determine the effectiveness of exercise on hot flashes.[16] In a recent study, regular exercise did not alleviate hot flashes, but did result in improved sleep and mood.[17]

Additionally, exercise promotes blood flow to the genital region, which improves vaginal dryness. At least one orgasm a week is recommended for women, either by themselves or with someone else, to encourage healthy blood flow and improve nerve sensation.¹⁶ Women with vaginal dryness should use a vaginal moisturizer daily to maintain moisture and flexibility, while improving blood flow. The product should be massaged in small, circular strokes into the inner vagina and outer vulvar region once a day for five minutes, using a vibrator for internal placement and massage. A lubricant may be necessary with intercourse to prevent worsening dryness. For women who continue to experience vaginal dryness despite these interventions, intravaginal estrogen will significantly improve symptoms. For more information, refer to the “Menopause” and “Hormone Replacement Therapy” Whole Health tools.

Food and Drink

Especially at this time, a healthy diet should be encouraged to maintain an optimal body weight. For many, this diet incorporates whole, unprocessed foods consisting of primarily fruits and vegetables, whole grains, and low-fat protein. For more information, refer to the “Food and Drink” Whole Health overview. Foods high in calcium should be encouraged, with the goal of 1,000-1,200 mg daily as recommended by the Institute of Medicine.[18]

Consider adding sources of phytoestrogens, which are plant compounds with structures similar to estrogen that result in their ability to cause estrogenlike effects on the body. Sources of phytoestrogens include soy (isoflavone) and flaxseed (lignan). For more information, refer to the “Phytoestrogens” Whole Health tool.

Power of the Mind

Exploration of the mind-body connection can bring awareness to menopause as a life transition. Helpful tools include breathing exercises, mindfulness meditation, yoga, tai chi , or Guided Imagery. “Mastering Menopause,” a CD by Belleruth Naparstek, includes Guided Imagery practices to help with sleep, reinforce self-esteem, and redefine beauty and aging.

Expore stress management techniques. The body’s stress hormone, cortisol, is made from precursors that include progesterone. With an increasing need for cortisol production because of high stress, progesterone levels may decrease, disrupting the balance of estrogen and progesterone in the body. Review approaches for decreasing stress, in addition to coping techniques, relaxation exercises, and mind-body practices.

Spirit and Soul

Menopause is a great time to explore a connection in life that gives a greater sense of meaning and purpose. Helpful tools include journaling, meditation, or connecting with religious or spiritual communities. Connecting with wise, older women who have transitioned into and through menopause can be a powerful experience.

Vitamin D

The Institute of Medicine recommends 600 IU daily for women age 70 and under and 800 IU daily for women older than 70.[18] Consider checking a vitamin D level or supplementing with higher doses of 1,000-2,000 IU daily for women at higher risk of deficiency (northern/southern climates, darker skin, elderly) to help support bone health.

Black Cohosh (Cimicifuga racemosa)

Black cohosh is an herb with estrogenlike properties. Results are inconsistent for the effects of black cohosh on menopausal symptoms, with significant variation among the preparations studied. A 2012 Cochrane review concluded that the evidence for use of black cohosh for menopausal symptoms is insufficient; however, “there is adequate justification for conducting further studies in this area.”[19] The most conclusive evidence is for a commercial product Remifemin, containing 1 mg of black cohosh triterpenes per 20 mg tablet. Studies show it significantly reduces menopausal symptoms and hot flash frequency when compared to placebo.[20] The standard dose is 40 mg once or twice daily. Side effects are rare, and most common is mild gastrointestinal discomfort. Because a small number of women have experienced liver problems while taking black cohosh, consider monitoring liver function tests and avoid use in women with liver disease. Use of black cohosh for longer than six months has not been studied, including its effects on endometrial hyperplasia.

St. John’s wort (Hypericum perforatum)

Commonly used for depression, St. John’s wort has been shown to improve mood and climacteric complaints in menopausal women. In one particular study, women using the combination of St. John’s wort and black cohosh reported improved scores for general menopausal symptoms and depression when compared to placebo.[21] The suggested dose is 300 mg three times daily, standardized to 0.3% hypericin or 4-5% hyperforin. St. John’s wort is generally tolerated well but should be used with caution in combination with other medications metabolized through the P450 system.

Although extensive research has not yet been done, some women find significant benefit from complementary therapies and approaches such as acupuncture, energy work, Chinese medicine, or Ayurveda. Acupuncture has shown to reduce the frequency and severity of vasomotor symptoms in perimenopause and menopause, both individually and as adjunctive treatment.[22] Research also supports its use in reducing sleep disturbances caused by menopause-related symptoms.[23] Use of mindful awareness, meditation, and clinical hypnosis have not been shown to improve menopausal symptoms. [24] Tai chi has been shown to improve overall general health, vitality, and bodily pain.[25] One must consider potential side effects and risks when considering these therapies, though with acupuncture and tai chi they tend to be quite rare.[26]

Hormone Replacement Therapy (HRT)

Hormone replacement therapy (HRT) is the most effective treatment for vasomotor menopausal symptoms. For many years, clinicians used systemic HRT to treat women in menopause, believing that HRT could benefit cardiovascular health, prevent osteoporosis, and help women live longer and healthier lives. In 2002, however, the Women’s Health Initiative (WHI) changed this practice. The trial was stopped early because the results showed that the risks of hormone replacement with estrogen and progesterone in women with a uterus outweighed the potential health benefits. Subsequent research has further clarified the risks associated with HRT, as critics felt that the results of the WHI trial could not be generalized because the participants were older (primarily 60s and 70s) and used only oral preparations of estrogen and progesterone.

The risks of hormone replacement therapy vary with the type, dose, route of administration, duration of use, and age of initiation. Research has shown that oral HRT (both estrogen-only and combined estrogen and progesterone) increases the risk of thromboembolic events, with risk of stroke increasing with age, and with initiation of therapy >10 years from onset of menopause. Estrogen plus progesterone therapy is associated with a small increased risk of breast cancer, which is greater with use of synthetic progestins (i.e., medroxyprogesterone acetate). HRT is also associated with an increased risk of gallbladder disease, although overall risk is low.[27][28]

For many women, HRT can be used safely to help manage menopausal symptoms, using the lowest effective dose to treat symptoms and minimize risks. The “Hormone Replacement Therapy provides more information.

Bioidentical Hormone Therapy

Since publication of the WHI trial, alternatives for the treatment of menopausal symptoms have become popular, including bioidentical hormone replacement therapy (BHRT). Bioidentical hormones, by definition, are identical in chemical structure to those hormones made by the body. Often the media refers to these hormones as “natural;” however, “natural” can have many meanings. Some use “natural” to suggest that the hormones come from nonsynthetic or nonartificial sources (such as wild yams or soybeans). Others use “natural” to describe the process of supplementing hormone levels and types that are similar to those levels and types in the human body. By definition, “bioidentical” only communicates that the hormone structure is identical to that of the body.

Compounded bioidentical hormones are custom-made formulations of multiple bioidentical hormones. Many women seek out compounded BHRT, believing it to be safer than standard HRT. Many of these formulations are not approved by the Food and Drug Administration (FDA). However, the FDA has approved bioidentical pharmaceuticals of both estrogen and progesterone that are carefully controlled and regulated, allowing for improved safety and known risks. If women are interested in using bioidentical hormone therapy, consider the FDA-approved products.

Hormone replacement therapy significantly improves the symptoms of menopause. Because of the risks, using HRT/BHRT should be an individual decision that each woman makes with help from her provider based on her attitude toward menopause, menopausal symptoms, personal medical history, and family history. Refer to the “Hormone Replacement Therapy” Whole Health tool has more information.

Through the process of completing her personal health inventory, Julie realized the importance of connecting with friends and getting involved in her community through church and volunteer activities. She started to keep a journal and devoted time most days to a meditative practice. By taking care of herself in this way, she felt healthier and comforted by the importance of setting a good example for her children.

Julie started using black cohosh regularly and increased her daily intake of dietary phytoestrogens. To promote bone health, she ensured adequate intake of both calcium and vitamin D and varied her activities at the local gym to include muscle strengthening and resistance training activities. She found a guided meditation for menopausal women on the Internet and listened to it regularly. She committed to a daily routine of vaginal massage using a moisturizer, which helped with dryness during intercourse. After a long discussion on the risks and benefits of hormone replacement, she decided to consider a trial of intravaginal estrogen if vaginal dryness persisted despite regular moisturizing massage. Although hot flashes were still present, she was better able to tolerate them.

Books

• Better than I Ever Expected: Straight Talk About Sex after 60, Joan Price (2006)
• Our Bodies, Ourselves: Menopause, Boston Women’s Health Book Collective (2010)
• Women’s Bodies, Women’s Wisdom: Creating Physical and Emotional Health and Healing, Christiane Northrup, MD (2010)

Retail

• A Woman’s Touch: Products and information

“Women’s Health” was written and updated by Anne Kolan, MD (2014, updated 2020).