Clinical experience and scientific evidence
support medicinal herbs, nutritional supplements, and lifestyle interventions for
common female endocrine disorder
Affecting more than five million women in the United
States alone, polycystic ovarian syndrome (PCOS) is one of the leading reasons
for female infertility.1 While the cause of PCOS is currently
uncertain, complex, and variable, this hormonal endocrine disorder manifests
itself through a spectrum of symptoms, including infertility, irregular or lack
of menstruation (known as amenorrhea), lack of ovulation, multiple cysts on the
ovaries, acne, excessive facial hair (hirsutism),
and obesity (although many women with PCOS are of normal weight — referred to
as “lean” PCOS). Women with PCOS typically have higher-than-normal levels of
male hormones, particularly testosterone, and lower-than-normal levels of the
female hormone progesterone, and
sometimes also have increased levels of the hormone prolactin, as well as abnormal
insulin regulation. In addition to infertility, PCOS significantly increases the
likelihood of miscarriage and infant death during or shortly after birth, and also
can lead to serious health issues in the woman, including endometrial cancer, osteoporosis,
heart disease, and diabetes.1
Drugs prescribed for PCOS include oral contraceptives, which decrease male
hormone levels and may normalize a woman’s menstrual cycle, and metformin (brand
name Glucophage®),
a drug commonly used to treat type 2 diabetes that has been found to help PCOS patients
regulate insulin levels and support conception.1 PCOS patients who
are trying to conceive are sometimes prescribed clomiphene (Clomid,™
Serophene®),
a fertility drug that stimulates ovulation.
These pharmaceuticals, unfortunately, are not without significant shortcomings.
Oral contraceptives often produce myriad side effects, cannot be used by women
with PCOS who are trying to conceive, and often worsen insulin resistance in PCOS
patients.2 Clomid can lead to undesired multiple-birth pregnancies,2
and the US Food and Drug Administration (FDA) warns that it increases major
birth defect risks and should not be used in pregnancy.3 And, although
metformin is showing potential to help manage PCOS symptoms and perhaps
increase conception chances, some women experience discouraging gastrointestinal
side effects from the drug,4 which has not been approved by FDA to
treat PCOS.1
“Herbs are important as there are few
truly effective pharmaceutical options,” said Jillian Stansbury, a naturopathic
physician and author of The PCOS Health
and Nutrition Guide (Robert Rose, 2012). “Herbs are a safe and nutritive
option to support ovarian function, endocrine feedback loops, thyroid function,
and blood sugar regulation and metabolism. I have had a great many patients
with PCOS over the years, and can report overall good success in treating the
various forms and presentations of PCOS: helping women lose weight, restoring
normal menses, helping infertile women to conceive and carry the pregnancy, and
improve metabolic function and prevent diabetes” (email, February 11, 2013).
Integrative medicine physician, herbalist, and
midwife Aviva Romm, MD, agrees that herbs also play a significant role in PCOS
treatment. “Weight loss is the most effective intervention, and metformin
is actually not a bad option, but of course herbs are natural and generally
safe so a great option to at least try for folks wanting to avoid
pharmaceuticals,” said Dr. Romm (email, February 10, 2013). “They might be
particularly helpful in the insulin resistance aspects of the condition, as
well as stress hormone mediation.”
Author of the PCOS section in Dr. Romm’s 2010 book Botanical Medicine for Women’s Health (Churchill Livingstone, 2010),
Angela Hywood, ND, illustrates the potential that herbs offer for this complex
condition by discussing a successful case report. The PCOS patient took six
herbs — chaste tree berry (Vitex agnus-castus), licorice (Glycyrrhiza glabra), white peony (Paeonia lactiflora), gymnema (Gymnema sylvestre), echinacea (Echinacea spp.), and schisandra (Schisandra chinensis) — in addition to eating a low-carbohydrate
diet. According to the report:
After five months on the
herbal protocol, the patient’s cycle regulated to a 32-day length…. Problematic
symptoms such as mastalgia [breast pain], acne, and hirsutism diminished
significantly during the five-month program. The lipid profile has improved to
within normal ranges…. She lost a total of 12 percent body weight in the five
months. The client became pregnant in her second month of actively trying to
conceive.2
Natural treatment plans for PCOS focus on addressing three main types of PCOS manifestations:
(1) hormonal imbalances; (2) insulin, blood sugar, and metabolic sensitivities
and/or irregularities; and (3) stress response and management.
“My general approach has emphasized
diet and exercise as a foundational therapy,” said Dr. Stansbury, “and I create
specific herbal and nutritional protocols for individual patients. Because PCOS
has many presentations, there could be a variety of different approaches to
address specific presentations.”
Herbs for Balancing Hormones in PCOS
Because PCOS is an endocrine disorder, herbs that balance hormone levels can be
very helpful in improving most PCOS symptoms, including amenorrhea,
infertility, acne, and unwanted facial hair. Women who have been diagnosed with
PCOS, or those who think they might have PCOS, should obtain a blood test to
determine if their testosterone and/or prolactin levels are increased. If they
are, Dr. Stansbury suggests chaste tree berry, licorice, and the Traditional
Chinese Medicine (TCM) herb dong quai
(Angelica sinensis) to restore normal
menses.
“I have seen many amenorrheic women be able to regain their menses — some of
them quite quickly,” said Dr. Stansbury. “I remember one case with a woman who
hadn’t had a menses for several years begin to menstruate after two weeks on an
herbal formula. And then we did some trial-and-error, and when we stopped [the
formula], her menses would stop again.”
Chaste tree has been used for thousands of years for numerous women’s health
issues, including menstrual disorders. Although no existing studies have directly
examined its effects in PCOS patients, a decent collection of published
scientific and clinical evidence supports its ability to treat some of the
condition’s symptoms.5 As Tori Hudson, ND, writes in her book Women’s Encyclopedia of Natural Medicine
(Keats Publishing, 1999), several clinical trials on women with amenorrhea have
found chaste tree to result in normal menstrual cycles. Likewise, Dr. Hywood writes
in Botanical Medicine for Women’s Health
that the available scientific literature suggests efficacy for chaste tree in
decreasing elevated prolactin levels and improving fertility and the body’s
progesterone-producing process.2
For women whose PCOS-related hormone imbalances are making conception
difficult, Dr. Stansbury recommends chaste tree berry, dong quai, kudzu
(Pueraria spp.), and knotweed (Polygonum spp.). Although
these herbs have been shown in her clinical practice to help women with PCOS
conceive, Dr. Stansbury notes that success varies and can take longer when
working toward this more complex outcome, and thus several herbal combinations
are often formulated and tried for the individual patient. Dr. Hudson suggests
chaste tree be taken for at least three or four months.5
Additional menstruation/hormonal balancing herbs recommended by naturopathic
doctors and herbalists based on their clinical experience and traditional
history include: red raspberry (Rubus idaeus) leaf, ginger (Zingiber officinale),
rosemary (Rosmarinus officinalis), feverfew
(Tanacetum parthenium), partridge
berry (Mitchella repens), mugwort (Artemisia vulgaris), and false
unicorn (Chamaelirium luteum) root — a
North American herb with an at-risk conservation status — as well as the phyto-estrogenic
herbs black cohosh (Actaea racemosa), red
clover (Trifolium pratense) flower, alfalfa
(Medicago sativa), flax (Linum usitatissimum) seed, soy
(Glycine max), and hops (Humulus lupulus).2,5-7
(For herb use during pregnancy, please see the “Conclusion” section below.)
Although little human clinical research has been conducted on herbs
specifically for PCOS treatment, some new studies present exciting
possibilities. A traditional Japanese formulation of licorice and white peony —
called Shakuyaku-Kanzo-To — has been
shown in trials on women with and without PCOS to decrease testosterone levels,
stimulate ovulation, and help with conception.2 A 2013 Iranian study
on wood betony (Stachys lavandulifolia)
found that this mint-family herb improved abnormal uterine bleeding in PCOS
patients as well as synthetic progesterone, and also that it lowered
testosterone levels and improved ovarian condition more than the progesterone.8
Similarly, a study on the black cohosh root extract Klimadynon®
(an ethanolic extract produced by German company Bionorica) found that it
increased PCOS patients’ progesterone levels, significantly reduced luteinizing hormone levels,
and improved ovulation and endometrial thickness more than Clomid.9
Although pregnancy rates were higher in the black cohosh group, the difference
was not statistically significant.
Herbs for Improving Insulin Regulation
Many women with PCOS have insulin resistance, also known as metabolic syndrome,
which presents itself through weight gain and high blood pressure, blood sugar,
and cholesterol. Others experience insulin resistance-related hyperinsulinemia,
which is higher-than-normal levels of insulin in the blood that can cause hypoglycemia
(low blood sugar), producing symptoms such as lightheadedness, nausea, shaking
hands, confusion, and more. A woman who has been diagnosed with PCOS or who
thinks she might have the condition can have her blood tested for these insulin
sensitivities. If she is found to exhibit full or partial manifestations, the
pharmaceutical metformin is usually prescribed, and several herbs and foods
exhibit similar insulin-related activities.
Due to their inositols and related compounds, Dr. Stansbury noted that legumes
are especially good for PCOS women with insulin concerns.
“These compounds work together to treat insulin resistance,” she said. “They
support signal transduction, the ability of a cell to receive insulin and then
tell the nucleus of the cell to respond to it.”
Not only have inositols garnered positive clinical outcomes among herbalists
and NDs, but their use in treating PCOS also has been supported by clinical
trials. A randomized, controlled clinical trial published in a 2010 issue of
the journal Gynecological Endocrinology,
for example, found that a daily dosage of 4
grams myo-inositol and 400 mcg folic acid significantly increased ovulation and
conception rates in infertile PCOS women compared with 1,500 mg daily of
metformin.10 Although another inositol form — d-chiro-inositol — has
been shown in earlier human studies to be very effective at treating PCOS,11
more recent research suggests myo-inositol — or perhaps a combination of the
two forms12 — may be just as effective.13 Studies are
currently comparing the two against each other. Good
sources of inositols are brown rice (Oryza sativa), soy, kidney
beans (Phaseolus vulgaris), garbanzo beans
(Cicer arietinum), carob (Ceratonia siliqua) —
available in powder form or in supplements — astragalus (Astragalus membranaceus), and alfalfa, as well as legume-family
herbs like licorice. Small amounts of d-chiro-inositol are found in buckwheat. Inositol
supplements are also available over-the-counter at many health food stores.
The mineral chromium also helps with insulin signal transduction. According to
the PCOS section in the 2010 book Integrative
Women’s Health, chromium is supported by “accumulating evidence” for
enhancing “the metabolic action of insulin and decreasing total cholesterol and
LDL…. It has the greatest benefit on obese, insulin-resistant individuals.”4
Integrative medicine physician and author of this section Bridget Bongaard, MD,
recommends 200-1,000 mcg of chromium picolinate per day.
Dr. Bongaard additionally advises PCOS patients to consider ingesting moderate
amounts of tea (Camellia sinensis) and/or
coffee (Coffea arabica) due to caffeine’s
well-documented ability to improve insulin sensitivity, taking 1 to 6 g daily
of cinnamon (Cinnamomum verum) for
its ability to improve insulin resistance and reduce fasting blood glucose — activities
exhibited in human trials — or 200 to 400 mg of alpha-lipoic acid to reduce
insulin resistance and oxidative stress.4 Dr. Hywood writes that the
traditional anti-diabetic Indian herb gymnema has been shown in experimental
models to lower blood sugar levels by preventing glucose absorption, and that fish
oil may also benefit PCOS patients due to its reduction on serum triglycerides.2
Herbs for Stress Response and Management
An important yet perhaps less-recognized aspect of PCOS treatment is managing a
patient’s stress levels. As Dr. Hywood explains, “In response to stress, the
adrenals release cortisol, inducing an elevation in prolactin … and increased
androgen synthesis, which in turn leads to menstrual cycle dysregulation,
especially anovulation, characteristic of PCOS.” In fact, Dr. Hywood notes that
botanical PCOS treatments should first address stress and that adaptogenic
herbs “should be given primary consideration.” She lists the following herbs as
helpful adaptogens for PCOS treatment: ashwagandha (Withania somnifera),
ginseng (Panax spp.), licorice,
rhaponticum (Rhaponticum carthamoides), rhodiola (Rhodiola rosea), and schisandra. These
adaptogens, she writes, “improve resistance to stress through [modulation] at
the adrenal level.”
In Integrative Women’s Health, Dr. Bongaard
recommends various mind-body therapies, including yoga, guided visualization,
hypnosis, biofeedback, and aromatherapy for decreasing stress hormones and
improving blood pressure and blood sugar. A recent study conducted in India and
published in the July 2012 issue of the International Journal of Yoga found that
a daily hour-long yoga and meditation program improved anxiety symptoms in
teenage girls with PCOS.14
Conclusion
Additional supportive therapies for PCOS include nurturing a healthy liver — an
organ crucial to the breaking down of excess hormones — particularly through
limiting alcohol intake and ingesting liver-supportive herbs like milk thistle
(Silybum marianum).6 Dr.
Stansbury highlighted the significant role that alcohol plays in women with
PCOS, whom she recommends consume just a few alcoholic drinks per week.
“Alcohol has one of the biggest glycemic indices of any food-stuff, more than
eating a spoonful of sugar. So if anyone is prone to insulin resistance,
quantities of alcohol will just challenge your blood sugar regulation. Alcohol
also challenges the liver, of course, and if your liver is busy detoxifying
alcohol, then it has less enzymes or less power and reserves to metabolize your
hormones.”
Regular and moderate exercise and resultant weight loss is paramount for
overweight PCOS patients as it reduces insulin and testosterone levels — often
providing dramatic relief of most PCOS symptoms.2,4 “Weight loss
alone,” writes Dr. Hywood, “has led to achievement of pregnancy in 60% of cases
without other medical intervention.” Likewise, low-carb diets also have been
shown in clinical experience and human studies to reduce insulin resistance and
testosterone levels in women with PCOS.15
Although women with PCOS are understandably eager to improve their symptoms,
enjoy an improved quality of life, and, often times, to start a family, they
must keep in mind that herbal, nutritional, and lifestyle therapies can take
time.
“[Women] might notice improvement as early as a month or two,” said Dr.
Stansbury, “but since this is shifting your whole hormonal balance and acting
on the liver and adrenals and ovarian function and pituitary feedback loops, I
give women a six-month to 12-month game plan.”
If a woman with PCOS conceives a child, most of the herbs recommended above
should not be used during pregnancy, unless recommended by the patient’s
healthcare provider.2 A few — including ginger, red raspberry leaf,
echinacea, and partridge berry — have safe pregnancy profiles.6 Of
course, as in most cases, readers are advised to consult their healthcare provider
for more information.
Lindsay Stafford Mader
References
- Polycystic
ovarian syndrome (PCOS) fact sheet. Office on Women’s Health website.
Available at: http://womenshealth.gov/publications/our-publications/fact-sheet/polycystic-ovary-syndrome.cfm#b.
Accessed February 15, 2013.
- Romm A. Botanical Medicine for Women’s Health.
St. Louis, MO: Churchill Livingstone; 2012.
- Goodman B.
Infertility treatments may raise birth defect risk. WebMD Health News. May
5, 2012. Available at: www.webmd.com/infertility-and-reproduction/news/20120505/infertility-treatments-may-raise-birth-defect-risk.
Accessed February 15, 2013.
- Maizes V, Low
Dog T (eds.). Integrative Women’s
Health. New York, NY: Oxford University Press, 2010.
- Hudson T. Women’s Encyclopedia of Natural
Medicine: Alternative Therapies and Integrative Medicine. Los Angeles,
California: Keats Publishing; 1999.
- Hobbs C,
Keville K. Women’s Herbs, Women’s
Health. Loveland, Colorado: Botanica Press; 1998.
- Gladstar R. Herbal Healing for Women. New York,
NY: Fireside; 1993.
- Jalilian N,
Modarresi M, Rezaie M, Ghaderi L, Bozorgmanesh M. Phytotherapeutic
management of Polycystic Ovary Syndrome: role of aerial parts of wood
betony (Stachys lavandulifolia).
Phytother Res. 2013. DOI:
10.1002/ptr.4921.
- Kamel HH. Role
of phyto-oestrogens in ovulation induction in women with polycystic
ovarian syndrome. European Journal
of Obstetrics & Gynecology and Reproductive Biology. 2013;(10.1016/j.ejogrb.2012.12.025).
- Raffone E, Rizzo P, Benedetto V.
Insulin sensitiser agents alone and in co-treatment with r-FSH for
ovulation induction in PCOS women. Gynecol Endocrinol.
2010;26(4)275-280.
- Nestler J, Jakubowicz D, Reamer P, Gunn R,
Allan G. Ovulatory and metabolic effects of d-chiro-inositol in the
polycystic ovary syndrome. N Engl J
Med. 1999; 340:1314-1320.
- Nordio M, Proietti E. The combined therapy
with myo-inositol and D-chiro-inositol reduces the risk of metabolic
disease in PCOS overweight patients compared to myo-inositol
supplementation alone. Eur Rev Med
Pharmacol Sci. 2012;16(5):575-81.
- Galletta M, Grasso S, Vaiarelli A, Roseff
SJ. Bye-bye chiro-inositol
- myo-inositol: true
progress in the treatment of polycystic ovary syndrome and ovulation
induction. Eur Rev Med
Pharmacol Sci. 2011 Oct;15(10):1212-4.
- Nidhi R, Padmalatha V, Nagarathna
R, Amritanshu R. Effect of holistic yoga program on anxiety symptoms in adolescent girls with
polycystic ovarian syndrome: A randomized control trial. Int J Yoga. 2012 Jul;5(2):112-7. doi:
10.4103/0973-6131.98223.
- Mavropoulos
JC, Yancy WS, Hepburn J, Westman EC. The effects of a
low-carbohydrate, ketogenic diet on the polycystic ovary syndrome: A pilot
study. Nutr Metab (Lond). 2005;2:35.
|