PMS and PCOS

1
PMS and PCOS

• Dr Craige Golding
• MBCHB, FCP(SA), ABAARM, FAAFM
• Board certified antiaging physician

2
PMS

• PMS is a hormonal disorder characterized by the
  monthly recurrence of certain physical or
  psychological symptoms during the two weeks
  before menstruation and the subsiding of those
  symptoms when flow begins or slightly afterwards.

3
Common PMS Symptoms

• Abdominal bloating
• Acne
• Angry outbursts
• Anxiety
• Appetite changes
• Asthmatic attacks
• Avoidance of social activities
• Backache
• Bladder irritation

4
Common PMS Symptoms (Cont.)

• Bleeding gums
• Breast swelling/tenderness
• Bruising
• Clumsiness
• Confusion
• Conjunctivitis
• Constipation
• Cramps
• Craving salty foods or sweets

5
Common PMS Symptoms (Cont.)

• Crying spells
• Decreased hearing
• Decreased productivity
• Decreased sex drive
• Depression
• Distractibility
• Dizziness
• Drowsiness
• Eye Pain

6
Common PMS Symptoms (Cont.)

• Facial swelling
• Fatigue
• Fear of going out alone
• Fear of losing control
• Finger swelling
• Food sensitivity
• Forgetfulness
• Aches and pains
• Headaches

7
Common PMS Symptoms (Cont.)

• Herpetic outbreak
• Hives or rashes
• Hot flashes
• Alcohol sensitivity
• Sensitivity to light and noise
• Inefficiency
• Indecision
• Insomnia
• Irritability

8
Common PMS Symptoms (Cont.)

• Joint pains
• Leg cramps
• Leg swelling
• Mood swings
• Nausea
• Palpitations
• Panic attacks
• Poor coordination
• Poor judgment

9
Common PMS Symptoms (Cont.)

• Poor memory
• Poor vision
• Restlessness
• Ringing in ears
• Runny nose
• Seizures
• Sinusitis
• Sore throat
• Spots in front of eyes

10
Common PMS Symptoms (Cont.)

• Suspiciousness
• Tearfulness
• Tension
• Tingling in hands and feet
• Tremors
• Visual changes
• Vomiting
• Weight gain

11
PMS is Frequently Misdiagnosed as a Psychological
Problem

• Anxiety disorder
• Depression
• Seizure disorder
• Panic attacks
• Agoraphobia
• Eating disorders
• Various personality disorders

12
PMS

• Can be treated with a better than 90 success
  rate.
• There is no definitive diagnostic test that
  confirms a diagnosis of PMS.
• There is no clear course of development. However,
  something in the patients lives interferes with
  the pituitary-ovarian feedback loop, and it
  decreases the supply of progesterone.

13
Precipitating Factors For PMS

• Oral contraceptives due to progestin
• Pregnancies
• Miscarriages and abortions
• Tubal ligations
• 37 of women who have a tubal ligation develop
  PMS and other complications such as pelvic pain
  and irregular cycles.
• Studies have shown that after tubal ligation
  women have higher estrogen and lower progesterone
  levels in the second half of their cycles.

14
Precipitating Factors For PMS (Cont.)

• Partial hysterectomy
• Even in patients who never had PMS before due to
  the decreased supply of blood to the ovaries post
  hysterectomy
• Age

15
Key Factor

• Low blood sugar
• Due to hormonal changes a womans body becomes
  more sensitized to drops in blood sugar the last
  two weeks of the cycle
• Symptoms of hypoglycemia are very much like PMS
  symptoms
• Treatment
• 6 small meals a day
• No refined sugars
• B6 which is needed for the production of dopamine
  and serotonin (Use B complex)
• VOID caffeine and alcohol who are antagonist to B
  vitamins

16
Caffeine

• Caffeine makes things worse
• Increases the bodys production of prostaglandins
  which increase during the premenstrual period and
  can cause breast tenderness, arthritis, abdominal
  cramping, headaches and backaches
• Acts as a diuretic which depletes the body of
  potassium, magnesium, B and C vitamins
• Causes the release of adrenalin which can lower
  blood sugar

17
Migraine Headaches

• Hormonally related migrainesTest
• Did the headaches have their onset at puberty, or
  after first taking contraceptive pills, or after
  a pregnancy?
• Did the attacks occur at the same time of each
  cycle?
• Free from headaches during the later states of
  pregnancy?
• Increases in severity of headaches after each
  pregnancy, abortion or miscarriage?

18
Four Main Mechanisms of Hormonally Related
Headaches

• Estrogen and progesterone increase at the time of
  ovulation. This can precipitate a headache.
  Estrogen binds salt in the body which may cause
  edema including swelling of the tissues in the
  brain.
• Hypoglycemia
• Changing estrogen levels
• Estrogen dominance

19
Edema

• Avoid foods with high sodium content
• Incorporate foods into the diet that are natural
  diuretics like strawberries and parsley
• Use evening primrose oil (500-3,000 mg qd)
• Increase water intake
• Exercise
• Use progesterone which is a natural diuretic
• Try not to use prescription diuretics
• Use spironolactone using a prescription diuretic

20
Magnesium

• Women with PMS have low magnesium levels
• Eat foods high in magnesium
• Take magnesium supplements (400-600 mg)

21
Vitamin A

• Has been shown to relieve PMS symptoms
• Is a diuretic
• Combats stress and fatigue
• Is an antioxidant

22
Exercise

• Exercise helps with PMS symptoms
• Helps relieve painful muscles and joints, tension
  headaches, low back pain, lower body bloating,
  tiredness, and irritability

23
Herbal Therapies

• Black Cohash (Cimcifuga racemosa)
• Has a balancing affect on estrogen
• Relaxant
• Sedative
• Anti-spasmotic
• Chasteberry (Vitex agnus castus)
• Decreases LH and prolactin
• Raises progesterone and facilitates progesterone
  function
• Acts as a diuretic
• Murray, M., The healing Power of Herbs.
  California Prima Publications, 1995, p. 375.

24
Progesterone

• Very effective in treating PMS
• Use days 10-24 of cycle

25
PCOS

• Three criteria set up by the National Institutes
  of Health
• Irregular or absence of menstruation
• Excess androgen production
• Lack of other reasons for irregular or absence of
  cycles and excess androgens

26
PCOS (Cont.)

• Having ovarian cysts is not one of the three
  criteria for the diagnosis of PCOS
• Therefore, ovaries with many cysts does not
  necessarily mean that the patient has PCOS.

27
Signs and Symptoms of PCOS

• Obesity
• Irregular or absent menstrual cycles
• Infertility/recurrent miscarriage
• Hirsutism
• Oily skin/acne
• Alopecia
• Acrochordons (skin tags)
• Depression
• Ahene, S., et al., Polycystic ovary syndrome,
  Nurs Stand 2004 18(26)40-4.

28
Symptoms That Are Revealed Through Lab Results or
Other Tests

• Cysts on the ovaries
• High testosterone level
• Elevated insulin level/insulin resistance
• Elevated LH
• Decreased SHBG
• Abnormal lipid profile
• Hypertension

29
Causes of PCOS

• Many scientist believe that PCOS has a hereditary
  component.
• Atimo, W., et al., Familial associations in
  women with polycystic ovary syndrome, Fert
  Steril 2003 80(1)143-45.
• Gonzalez, C., et al., Polycystic ovaries in
  childhood a common finding in daughters of PCOS
  patients of PCOS patients. A pilot study, Hum
  Repro 2002 17(3)771-76.

30
Causes of PCOS (Cont.)

• There is some suggestion in the medical
  literature that women with PCOS are born with a
  gene that triggers higher than normal levels of
  androgen or insulin.
• Strauss, J., et al., Some new thoughts on the
  pathophysiology and genetics of polycystic ovary
  syndrome, Ann NY Acd Sci 2003 99742-8.
• Carey, A., et al., Evidence for a single gene
  effect causing polycystic ovaries and male
  pattern baldness, Clin Endocrinol 38(6)653-8.

31
Causes of PCOS (Cont.)

• Studies have shown that the high levels of
  testosterone and insulin in patients with PCOS
  are linked.
• This link is a gene called follistatin.
• Functions of follistatin
• Plays a role in the development of the ovaries
• Is needed to make insulin
• Urbanek, M., et al., Thirty seven candidate genes
  for PCOS Strongest evidence of linkage is
  follistatin, Proc Nat Acd Sci 1999 38(6)653-58.

32
Causes of PCOS (Cont.)

• Stress may be a contributing factor to PCOS.
• Marantides, D., et al., Management of polycystic
  ovary syndrome, Nurse Pract 1997 22(12)34-8,
  40-1.

33
Stress and PCOS

• Studies have shown that many women with PCOS
  cannot process cortisol effectively, leading to
  elevated cortisol levels in the body.
• Tsilchorozidou, T., et al., Altered cortisol
  metabolism in polycystic ovary syndrome insulin
  enhances 5 alpha-reduction but not the elevated
  adreanl steroid production rates, Jour Clin
  Eneocrino Metab 2003 88(12)5907-13.

34
Stress and PCOS (Cont.)

• When women are under stress, too much prolactin
  may be released. This may affect the ability of
  the ovaries to produce the right balance of
  hormones.
• Barnea, E., et al., Stress-related reproductive
  failure, Jour IVF Embryo Transfer 1991 815-23.

35
PCOS Risk Factor For Other Major Diseases

• Diabetes
• Pelusi, B., et al., Type 2 diabetes and the
  polycystic ovary syndrome, Minerva Ginecol 2004
  56(1)41-51.
• Heart Disease
• Talbott, E., et al., Cardiovascular risk in
  women with polycystic ovary syndrome, Obstet
  Gynedol Clin North Amer 2001 28(1)111-33.
• Hypertension
• Rajkhowa, M., et al., Polycystic ovary syndrome
  a risk for cardiovascular disease, BJOG Int
  Jour Obstet Gynecol 2000 107(1)11-8.

36
PCOS Risk Factor For Other Major Diseases (Cont.)

• Infertility
• Trent, M., et al. Fertility concerns and sexual
  behavior in adolescent girls with polycystic
  ovary syndrome implications for quality of
  life, Jour Pedatr Sdolesc Gynecol 2003
  16(1)33-7.
• Hormonally related cancers
• Radulovic, A., et al., Obesity and hormone
  function changes in female patients with
  polycystic ovaries, Med Pregl 2003
  56(9-10)476-80.
• Obesity
• Gonzalez, C., et al., Polycystic ovarian
  disease clinical and biochemical expression,
  Ginecol Obstet Mex 2003 71253-58.

37
Diabetes and PCOS

• PCOS is a risk factor for diabetes.
• Pelusi, B., et al., Type 2 diabetes and the
  polycystic ovary syndrome, Minerva Ginecol 2004
  56(1)41-51.
• If the patient has PCOS they are seven times more
  likely to get diabetes.
• Legro, R., et al., Prevalence and predictors of
  risk for Type 2 diabetes mellitus and impaired
  glucose tolerance in polycystic ovary syndrome a
  prospective, controlled study in 254 affected
  women, Jour Clin Endocrinol Metabol 1999
  84(1)165-69.
• About half of all women with PCOS have insulin
  resistance.
• De Leo, V., et al., Polycystic ovary syndrome
  and type 2 diabetes mellitus, Minera Ginecol
  2004 56(1)53-62.

38
Diabetes and PCOS (Cont.)

• Some studies suggest that women with PCOS who
  have irregular cycles or no cycles may have
  double the risk for diabetes.
• Solomon, C., et al., Long or irregular menstrual
  cycle as a marker for the risk of type 2 diabetes
  mellitus, JAMA 2001 286(19)2421-26.
• Risk factor for diabetes in patients with an
  irregular cycle increases even more if the
  patient is obese.
• Ibid., Solomon.

39
Diabetes and PCOS (Cont.)

• The risk of getting diabetes is also increased in
  patients with PCOS that are not overweight or
  insulin resistant.
• Danaif, A., et al., Beta cell dysfunction
  independent of obesity and glucose intolerance in
  the polycystic ovary syndrome, Jour Clin
  Endocrinol Metab 1996 81942-47.

40
Heart Disease and PCOS

• Women with PCOS have an increased risk of heart
  disease compared to women without PCOS.
• Christian, R., et al., Prevalence and predictors
  of coronary artery calcification in women with
  polycystic ovary syndrome, Jour Clin Endocrinol
  Metab 2003 88(6)2562-68.
• Wild, S., et al., Cardiovascular disease in
  women with PCOS A long-term follow up A
  retrospective cohort study, Clin Endocrinol
  (Oxf) 2000 52(5)595-600.
• Talbot, E., et al., Cardiovascular risk in women
  with polycystic ovary syndrome, Obstet Gynecol
  Clin North Amer 2001 28(1)111-33.

41
Heart Disease and PCOS (Cont.)

• Women with PCOS frequently have elevated LDL.
• Orio, F., et al., The cardiovascular risk of
  young women wit polycystic ovary syndrome an
  observational, analytical, prospective
  case-control study, Jour Clin Endocrinol Metab
  2004 89(8)3696-701.
• Homocysteine levels are increased in patients
  with PCOS.
• Loverro, G., et al., The plasma homocysteine
  levels are increased in polycystic ovary
  syndrome, Gynecol Obstet Invest 2002
  53(3)157-62.

42
Heart Disease and PCOS (Cont.)

• Women with PCOS have a higher than usual rate of
  elevated CRP.
• Boulman, N., et al., Increased C-reactive
  protein levels in the polycystic ovary syndrome
  a marker of cardiovascular disease, Jour Clin
  Endocrinol Metabol 2004 89(5)2160-65.

43
Heart Disease and PCOS (Cont.)

• Women with PCOS frequently have decreased total
  antioxidant status and increased oxidative
  stress.
• This pattern may be one of the contributing
  causes of heart disease in women with PCOS.
• Fenkev, I., et al., Decreased total antioxidant
  status and increased oxidative stress in women
  with polycystic ovary syndrome may contribute to
  the risk of cardiovascular disease, Fertil
  Steril 2003 8091)123-27.

44
Hypertension and PCOS

• Women with PCOS have four times the rate of
  hypertension than women who do not have PCOS.
• Lefebvre, P., et al., Long-term risks of
  polycystic ovaries syndrome, Gynecol Obstet
  Fertil 2004 32(3)193-98.

45
Hypertension and PCOS (Cont.)

• Insulin resistance and hyperinsulinemia raise
  blood pressure.
• Landsberg, M., Insulin sensitivity in the
  pathogenesis of hypertension and hypertensive
  complications, Clin and Experimental Hyper 1996
  18(3-4)337-46.

46
Hypertension and PCOS (Cont.)How
Hyperinsulinemia Causes HTN

• High levels of insulin correlate with low sodium
  in the urine.
• This leads to an increase in water retention
  which makes it harder for blood to flow through
  the circulatory system.
• Consequently leading to an increase in blood
  pressure.
• Insulin also elevates blood pressure by affecting
  the elasticity of arterial walls.

47
Hypertension and PCOS (Cont.)How
Hyperinsulinemia Causes HTN

• Insulin alters the mechanical action of the blood
  vessel walls by acting on smooth muscle cells
  stimulating them and making them larger.
• As smooth muscle cells grow, they make the
  arterial walls thicker, stiffer, and less supple.
  This forces the heart to work harder and exert
  more pressure to force the blood through the
  narrowed vessels.

48
Infertility and PCOS

• In women with PCOS, the ovarian follicles start
  to mature but fail to ripen or to be released.
• They stay in the ovaries and continue to produce
  estrogen, but no progesterone.
• Elevated levels of LH and estrogen have been
  found in some women with PCOS. This may block
  ovulation.
• Milsom, S., et al., LH levels in women with
  polycystic ovarian syndrome have modern assays
  made them irrelevant? British Journ of Obstec and
  Gynecol 2003 110(8)760-4.

49
Infertility and PCOS (Cont.)

• Higher than normal levels of testosterone are
  also found in PCOS patients. High levels of
  testosterone inhibits ovulation.
• Franks, S., The ubiquituous polycystic ovary,
  Jour Endocrinol 1991 129317-19.
• Women with PCOS may miscarry at a higher rate
  than women without PCOS.
• Diejomaoh, M., et al., The relationship of
  recurrent spontaneous miscarriage with
  reproductive failure, Med Princ Pract 2003
  12(2)107-11.
• Rai, R., et al., Polycystic ovaries and
  recurrent miscarriagea reappraisal, Hum Repro
  2000 15612-15.

50
Infertility and PCOS (Cont.)

• Insulin also plays a role in ovulation
• The ovaries have insulin receptors
• Insulin stimulates an increase in LH and androgen
  levels decreasing SHBG
• In the presence of elevated androgens, LH levels
  increase and lead to poor follicle development
  and failure to ovulate.

51
PCOS and Hormonally Related Cancers

• Women who had a history of PCOS and irregular
  periods have a five-fold increase in endometrial
  cancer.
• Hardiman, P., et al., Polycystic ovary syndrome
  and endometrial carcinoma, Lancet 2003
  361(9371)1810-12.
• Women who have a history of PCOS may have an
  increased risk of ovarian cancer.
• Spremovi, R., et al., The polycystic ovary
  syndrome associated with ovarian tumor, Srp Arh
  Celok Lek 1997 125 (11-12)375-77.

52
PCOS and Hormonally Related Cancers (Cont.)

• Women with a history of PCOS may be at risk for
  breast cancer since they tend to be over weight
  and have hormonal changes that can lead to
  unopposed estrogen in the body.
• Wild, S., et al., Long-term consequences of
  polycystic ovary syndrome results of a 31-year
  study, Hum Fertil (Camb) 2000 3(2)101-05.

53
Obesity

• Studies have shown that women with PCOS store fat
  better and burn calories at a slower rate than
  women who do not have PCOS.
• Robinson, S., et al., Postprandial thermogenesis
  is reduced in polycystic ovary syndrome and is
  associated with increased insulin resistance,
  Clin Endocrinol (Oxf) 1992 36(6)537-43.
• Faloia, E., et al., Body composition, fat
  distribution and metabolic characteristics in
  lean and obese women with polycystic ovary
  syndrome, Jour Endocrinol Invest 2004
  27(5)424-29.
• Gambineri, A., et al., Obesity and the
  polycystic ovary syndrome, Int Jour Obes Relat
  Metab Disord 2002 26(7)883-96.

54
Treatment of PCOS

• Medications
• Fiber
• Low GI program
• Reduce stress
• Essential fatty acids
• Drink enough water
• Antioxidants
• Herbal remedies

55
Medications

• Anti-androgen medications
• Aldactone (spironolactone)
• Tagament (cimetidine)
• Testosterone metabolism blockers
• Propecia (finsteride)
• Medications to lower blood sugar
• Glucophage (metformin) is the most successful
• Gonadotropin-Releasing Hormone Antagonists
• Lupron (leuprolide)

56
Medications (Cont.)

• Hair growth stimulators
• Rogaine solution (minoxidil)
• Hair metabolism inhibitors
• Vaniqa cream (eflornithine)
• Menstrual Regulators
• Progestins
• BCP
• Choose ones that are the least androgenic
  (desogestrel or norgestimate)
• Progesterone

57
Medications (Cont.) and Surgical Treatment of PCOS

• Ovulation Inducers
• Clomid/Serpjeme (clomiphene)
• Pergonal/Humegon/Repronex (hMG)
• Follistim/Gonal (FSH)
• Profasi/Pregnyl (HCG)
• Surgery
• Ovarian wedge resection
• Laparoscopic ovarian drilling

58
Fiber

• Fiber lowers blood sugar, blood pressure and
  cholesterol.
• Anderson, J., et al., Dietary fiber diabetes
  and obesity, Amer Jour Gasteroenterol 1986
  81898-906.
• Burke, V., Dietary protein and soluble fiber
  reduce ambulatory blood pressure in treatment of
  hypertensives, Hypertension 2001 38(4)821-26.
• Anderson, J., et al., High-fiber diets for
  diabetic and hypertriglyceridemic patients, Can
  Med Assoc Jour 1980 123975.
• Sprecher, d., et al., Efficacy of psyllium in
  reducing serum cholesterol levels in
  hypercholesterolemic patietns on high-or low-fat
  diets, Ann Inter Med 1993 119545-54.

59
Low Glyemic Index Diet

• Place the PCOS patient on a low glycemic index
  eating program.

60
Reduce Stress

• Cortisol stimulates the release of glucose, fats,
  and amino acids for the production of energy in
  the body.
• During times of stress, cortisol and insulin
  levels rise in the body. Cholesterol levels may
  rise as well.
• If cortisol is increased it decreases the making
  of progesterone and its activity. Cortisol
  competes with progesterone for common receptors.
  
• Bland, J., Introduction to neuroendocrine
  disorders, Functional Medicine Approaches to
  Endocrine Disturbances of Aging. Gig Harbor,
  Washington The Functional medicine Institute,
  2001 p. 121.

61
Reduce Stress (Cont.)

• Consequently, if cortisol levels are elevated,
  the symptoms of PCOS can be exacerbated.

62
Essential Fatty Acids

• Essential fatty acids slow down the absorption of
  carbohydrates into the blood stream.
• Kasim Karakas, M., et al., Metabolic and
  endocrine effects of a polyunsaturated fatty
  acid-rich diet in polycystic ovary syndrome,
  Jour Clin Endocrinol Metabol 2004 89(2)615-20.

63
Drink Enough Water

• The amount of water the body needs in one day is
  1/2 the body weight in oz. every day.
• People who drink 5 to 8 glasses of water a day
  have fewer heart attacks. Dehydration increases
  the tendency for the blood.
• Chan, J., et al., Water, other fluids, and fatal
  coronary heart disease, Amer Jour Epidemiol
  2002 155(9)827-33.

64
Nutritional Treatment of Insulin Resistance

• Chromium picolinate (400-600 micrograms)
• Decreases sugar cravings and improves insulin
  sensitivity
• Lipoic acid (200-600 mg)
• Improves insulin sensitivity and helps prevent
  neuropathy
• CLA (1,000-3,000 mg)
• Improves insulin sensitivity
• Zinc 25-50 mg)
• Helps balance blood sugar levels
• Vitamin E (600-800 IU natural)
• Helps balance hormonal function

65
Nutritional Treatment of Insulin Resistance

• Taurine (1,000-3,000 mg)
• Increases activity of insulin receptor and
  improves sensitivity to insulin
• Magnesium (400-800 mg)
• Improves glucose uptake
• Biotin (4-8 mg)
• Increases insulin sensitivity
• Vanadium (20-50 mg)
• Improves insulin sensitivity
• Vitamin D (400-2,000 IU)
• Helps pancreas release insulin

66
Nutritional Treatment of Insulin Resistance

• Co-enzyme Q-10 (30-300 mg)
• Provides energy for metabolic pathways
• B complex (50-100 mg)
• Aids in glucose metabolism and decreases sugar
  cravings
• Vitamin C (1,000-3,000 mg)
• Cofactor in glucose metabolism
• Manganese (5-10 mg)
• Aids carbohydrate metabolism
• Inositol (d-chiroinositol)
• Decreases insulin resistance
• Lentils, chickpeas, and broccoli all decrease
  insulin levels.

67
Reference

• Smith, P., Vitamins Hype or Hope. Traverse City,
  Michigan Healthy Living Books, 2004, p. 210-11.

68
Herbal Remedies

• Fenugreek
• Interferes with absorption and digestion of
  sugars
• Gymnema sylvestre
• Improves insulin sensitivity and interferes with
  the absorption of glucose
• Cinnamon
• Improves glucose utilization and increases
  insulin receptor sensitivity
• FOS
• Black Cohosh (Cimcifuga racemosa)
• Binds to estrogen receptors and lowers LH
• Chasteberries (Vitex agnus castus)
• Reduces prolactin secretion and lowers the
  estrogen-progesterone ratio

69
Supplements to Avoid With PCOS

• High doses of niacin
• Can worsen insulin sensitivity

70
Reference Book For Patients

• The PCOS Protection Plan by Colette Harris and
  Theresa Cheung. Hay House Inc. 2006.