Polycystic Ovarian Syndrome (PCOS)
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In a previous article we surveyed the field of female infertility. In this article we will look more deeply into one of the most common causes of menstrual irregularity, hormonal imbalances and infertility, a grouping of symptoms known as polycystic ovarian syndrome. We will see how Ayurveda brings added depth to the understanding of this poorly understood condition and can offer treatment options that are more than merely symptomatic.
With a prevalence of 6-10% of the female population, PCOS is a common cause of morbidity, infertility and quite possibly of increased risk of mortality. (1) PCOS is a syndrome characterized by multiple small cysts on the ovaries, menstrual irregularities and features of excess androgen production such as hirsutism (excess facial or body hair), male or female pattern balding, acanthosis nigrans and acne. Not all women affected with PCOS have all thee features but to make a diagnosis of PCOS, at least two of these three characteristics must be present. In terms of menstrual irregularity, menses may be irregular; there may be oligomenorrhoea (reduced frequency of menstruation) or amenorrhoea (periods of six months or more without menstruation). Menstrual irregularity is noted from menarche on. As one menopausal patient noted, "First I was told that my periods were irregular because I was young, then because I was under stress in school, then because I was travelling and then because I was premenopausal. From the day of menarche, my periods were never regular."
While not all women with PCOS have menstrual irregularity, those who do not must have both other sets of characteristics fully established in order to meet diagnostic criteria for PCOS. Typical androgenic features may include sideburn or chin hair, chest or belly hair, nipple hair, balding, acne and acanthosis nigrans, a darkening of skin on the nape of their neck, skin folds, knuckles, or elbows. If there are more intense symptoms of excess androgens such as enlarged clitoris, baldness, dropped voice and increased muscle mass, referral to an endocrinologist is needed to exclude other, more dangerous diseases that may lead to excess testosterone production. Polycystic ovaries must be established by ultrasound. Again, while not all PCOS sufferers actually have polycystic ovaries, those who do not must clearly show menstrual irregularities and hyper-androgenic features.
As well as these diagnostic features, PCOS is associated with obesity, particularly central obesity, insulin resistance, hypertension, raised blood lipids and metabolic syndrome. After a girlhood of menstrual problems and adult years of fertility issues, a woman with PCOS may enter her elder years with an increased risk of type II diabetes and heart disease (2). Yet despite the added mortality and morbidity associated with this condition, for many women, the most devastating feature of PCOS is its impact on fertility. Although not all women with PCOS experience fertility issues, many do. Conception may be difficult to impossible or there may be a history of miscarriages. For those who do become pregnant, there is an increased risk of gestational diabetes and hypertension.
After hearing these features of PCOS, the Ayurvedic practitioner has noticed the strong correlation with kapha issues. Although there may be pitta features such as acne and hair loss or vata features like menstrual irregularity, it is kapha that lies at the root of this syndrome. By the same token, although PCOS may affect any prakruti, as a kapha condition it is typically most severe in kapha prakruti. A majority of all women with PCOS seen in the author's practice have been of kapha prakruti.
A woman with PCOS may present complaining of hirsutism, acne, obesity or menstrual and fertility issues. In making a diagnosis of kapha syndrome with suspected PCOS, it is important to exclude other causes of similar issues. For example, a thirty two year old Indian woman of tridoshic vata constitution presented to an Ayurvedic physician complaining of hair loss, weight gain, acne, sluggishness and fertility issues. Her menstrual cycle was regular. The physician diagnosed PCOS, based on her reported symptoms. While booking an ultrasound to screen her ovaries, she presented for a second opinion. Based on her complaints of sluggishness, weight gain, hair loss and impaired fertility as well as clinical findings of leathery skin and abnormal thyroid pulse, we told her that thyroid issues were the likely cause of her complaints. Sure enough, her ultrasound showed normal ovaries, excluding the diagnosis of PCOS since she had both normal ovaries and a normal menstrual cycle. She unearthed three old thyroid tests all of which showed sub-optimal thyroid function. Although she did have some kapha syndrome issues, these were expressing more in terms of metabolic rate and the thyroid than in terms of PCOS. She was fortunate to have a treatable cause of her fertility concerns.
A thirty year old Ashkenazi Jewish woman of kapha prakruti complained of central obesity, dropped voice, facial hirsutism, amenorrhoea and infertility. Polycystic ovaries were shown on ultrasound. She had other kapha symptoms including chronic sinus congestion and was allergic to dairy. Although a vegan diet was a crucial self-care method for her, she found that exercise including strength training and cardio made the greatest difference to her symptoms, particularly to central obesity. Her journey with infertility was a tortuous one. After two devastating failed in-vitro fertilizations, she was able to carry a child successfully after IVF but could not establish lactation, a not-uncommon finding in PCOS (3). Nevertheless, she is happy with her precious baby.
A twenty seven year old kapha African-American woman had polycystic ovaries demonstrated by ultrasound. Eight years ago, she had one pregnancy which was complicated by hypertension and oedema. She had a strong family history of hypertension and raised blood lipids and was a former smoker. Two years ago, she was found to be hypertensive with raised cholesterol. She normalized these parameters by quitting smoking, exercising and giving up cheese. Currently she had significant hirsutism with sideburn hair, beard and moustache hair and belly hair and was suffering from irregular menses, overweight and malaise. At 165 lb she was 20 lb over her optimum. She responded extremely well to a kapha-soothing diet and to a formula which included Punarnava as dosha pratyanika for kapha, Shardunika to help insulin production and Chitrak for agni. Shilajit is a crucial component in the herbal management of PCOS, so clients will respond well to a formula which contains shilajit, such as Trim Support, as well as to a blend containing Shardunika, such as Sweet Ease.
A thirty seven year old Caucasian woman of kapha prakruti presented with an array of kapha complaints including sluggish digestion, plugged ears and chronic sinusitis. She had experienced amenorrhoea since her teens, menstruating only once a year and was developing female pattern baldness. Ten years ago she had an ultrasound and was found to have polycystic ovaries. She had also been diagnosed with insulin resistance. Currently she took depot provera which induced a period every 45 days. She had a strong tendency to gain weight. She was married and experiencing infertility. She tried to prepare healthy foods at home but had lunch most days at McDonald's, Burger King or Taco Bell. After switching to a kapha soothing diet and eliminating gluten and cow dairy, she improved significantly. And amazingly, after taking Trim Support and Triphala, she became pregnant. Yet the sweeping extent of her kapha syndrome turned joy to tears when she gave birth to a stillborn child as a result of multiple thromboses in the placenta. As a complication of PCOS, she suffered from thrombophilia--a tendency of the blood to clot in the blood vessels. Current research suggests that thrombophilia plays a key role in stillbirth and miscarriage in patients with PCOS. "Undetected thrombophilia is not only additional cause of infertility but sometimes the basic cause of infertility in patients with PCOS and MS (metabolic syndrome)." (4)
This patient had difficulty implementing a full program of Ayurvedic treatments due to an extremely busy life as a business owner. Her history reminds us of the importance of treating kapha at depth, including diet, lifestyle, kapha soothing herbs and pre-conception panchakarma, in an attempt to promote a positive outcome of pregnancy in PCOS. A rejuvenative and hormonally balancing formula such as Women's Support can be given following panchakarma to enhance fertility. During pregnancy, herbs such as Vidari should be given to nourish the placenta as well as kapha reducing herbs to lower stickiness of the blood and control kapha syndrome. Since Ashwagandha may be androgenic in action, it is wise to avoid using it in PCOS.
In Western medicine, there is no definitive treatment for PCOS. Management is largely symptomatic. Ayurveda can make a significant contribution to the wellbeing of women with PCOS by offering kapha soothing diet and lifestyle, kapha balancing yoga and kapha soothing herbs. Blood sugar and insulin resistance issues can be managed using Shardunika, neem, turmeric, bibhitaki and Sweet Ease, while scraping formulas like Trim Support will not only help lower weight but also may normalize the polycystic ovaries. Triphala Guggulu and turmeric will reduce blood stickiness, mitigating symptoms of thrombophilia (note that neither of these herbs is recommended during pregnancy). Vidari will support fertility and nourish the placenta. And panchakarma will normalize kledak kapha, helping to reduce thrombotic symptoms. Developing a good programme of self-care for kapha will not only help support the best possible outcomes during the woman's reproductive years but will also help prevent her developing diabetes and heart disease later in life.
Andrea J. Cussons, Bronwyn G. A. Stuckey and Gerald F. Watts1 Metabolic syndrome and cardiometabolic risk in PCOS Current Diabetes Reports, 2007 -springer link
Polycystic ovarian syndrome (PCOS): a significant contributor to the overall burden of type 2 diabetes in women.Talbott EO, Zborowski JV, Rager JR, Kip KE, Xu X, Orchard TJ.J Womens Health (Larchmt). 2007 Mar;16(2):191-7
Lisa Marasco, BA, IBCLC089033440001600211Polycystic Ovary Syndrome: A Connection to Insufficient Milk Supply? Journal of Human Lactation, Vol. 16, No. 2, 143-148 (2000) DOI: 10.1177/
Perederyaeva EB, Pshenichnikova TB, Makatsaria AD. INHERITED AND ACQUIRED THROMBOPHILIA IN PATIENTS WITH METABOLIC SYNDROME IN OBSTETRIC-GYNECOLOGIC PRACTICE. J Thromb Haemost 2007; 5 Supplement 2: P-T-608
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Alakananda Ma M.B., B.S. (Lond.) is an Ayurvedic Doctor (NAMA) and graduate of a top London medical school. She is co-founder of Alandi Ayurveda Clinic and Alandi Ayurveda Gurukula in Boulder Colorado, as well as a spiritual mother, teacher, flower essence maker and storyteller. Alakananda is a well known and highly respected practitioner in the Ayurveda community both nationally and internationally.
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