HerbalEGram: Volume 10, Number 3, March 2013

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

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12. 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.
13. 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.
14. 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.
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