THE PCCA BLOG

Nutritional and Lifestyle Support for PCOS

Wed, 17 May 2023 11:00:00 GMT

Polycystic ovary syndrome (PCOS) is the most prevalent hormonal disorder affecting women of reproductive age across the globe. The CDC estimates PCOS may be one of the most common causes of infertility, impacting 6-12% of reproductive aged women.¹In around 75% of cases, PCOS is the underlying cause in cases of amenorrhea (the absence of menstruation) in reproductive age women.

PCOS occurs when the ovaries produce excess androgens causing irregular ovulation and multiple ovarian cysts. Some of the symptoms of PCOS include menstrual irregularity or absent cycles, weight gain, fertility issues, fatigue, depression and abdominal pain. The overproduction of androgens associated may also lead to acne, hirsutism (abnormal growth of facial and body hair, notably in women) and male-pattern baldness.

Other risks are associated with this condition as well. Insulin resistance affects 50-70% of women with PCOS.²And it is estimated that more than half of the women with PCOS will develop type 2 diabetes by the age of 40.¹Women with PCOS are at higher risk of cardiovascular disease.³PCOS can also increase the risk of endometrial cancer.4

Managing PCOS

Although no official cure for PCOS exists, there are many ways to help manage PCOS including surgeries, pharmaceutical options, lifestyle changes and through nutrition.

In managing PCOS, some of the main goals are to reduce the risks of developing certain cancers, reduce androgen levels, reduce body weight and long-term cardiovascular risks, manage blood sugar and risk of diabetes, and to maintain healthy ovulation cycles.

In many cases, oral contraceptives may be prescribed to aid in inducing regular cycles. An example may include progesterone capsules if a patient has low progesterone levels. Anti-androgen medications such as Aldactone® or Tagamet® may be prescribed. It is common to utilize medications such as statins to help control blood sugar and lipids. Since statin medications deplete the body of coenzyme Q10 (COQ10), patients on statins may benefit from adjunct supplementation of COQ10. There are also natural therapies available that can be utilized in combination with medications or as an option to possibly prevent medications from becoming a necessity.

Although not all women with PCOS are overweight, maintaining a healthy weight is one of the best natural tools to help combat the condition. Regular exercise helps maintain a healthy weight and increase the body’s sensitivity to insulin. Adhering to a regular exercise regimen of 150 minutes of activity per week can reduce risks of cardiovascular disease and diabetes in women with PCOS. Regular exercise can also help alleviate symptoms of mood disorders associated with PCOS.⁵Of course, exercise works best in combination with a healthy diet.

A low-carbohydrate diet with a greater intake of fruits and vegetables, natural fibers, healthy fats and clean proteins is helpful in managing blood sugars, weight and overall cardiovascular health in women with PCOS.^6,7,8Lower carbohydrate intake helps reduce simple sugars in the diet, assist in insulin sensitivity and maintain a healthy weight. Adding fiber to the diet can also help manage weight, as well as improve dyslipidemia and insulin sensitivity.^6,7And replacing carbohydrates with clean proteins has been shown to improve glucose metabolism.⁸

Other dietary ingredients have shown promise for PCOS and blood sugar control. Vitamin D is important for reproductive hormones, inflammation, mood balance and for glucose homeostasis. Low vitamin D levels are quite common today. PCOS patients with low vitamin D levels may benefit from the addition of a high-quality D3 dietary supplement.

Inositol has also been shown to help improve endocrine and metabolic issues found in PCOS patients. Inositol is structurally similar to glucose and can influence hormones and insulin response. Myo-inositol and d-chiro-inositol work together as secondary messengers, relaying signals to support optimal blood glucose balance.^9,10The inositol pathway also plays a critical role in ovulation by promoting regular cycles, reducing androgen levels and improving fertility.^9,10,11A 40:1 ratio of myo- to d-chiro-inositol has been shown to aid the body in restoring healthy follicle-stimulating hormone, testosterone synthesis and balanced androgen.^9,10,11,12

Another natural ingredient that shows promise in alleviating PCOS symptoms is chromium picolinate. Chromium is foundational for its powerful ability to promote reproductive health by supporting ovulation, optimal blood glucose, a healthy body mass index (BMI) and balanced hormones.^13,14Studies showed chromium picolinate works similarly to metformin to decrease fasting blood sugar, has beneficial effects on decreasing BMI and free testosterone in PCOS patients.¹³

Another natural ingredient that may be beneficial is cinnamon, a common spice known for use in cuisines around the world. Cinnamon has also been used in ayurvedic and other traditional medicines as a means to assist in glucose control. Some studies showed a reduction in glucose and triglycerides using 3-6 grams of cinnamon per day.¹⁵Adding cinnamon in teas, cooking and with dietary supplements may be an added benefit for PCOS patients. Fenugreek and cinnamon are both backed by clinical studies showing their ability to help support optimal blood glucose balance and promote healthy menstrual cycles. Some studies have also shown a decrease in polycystic appearing ovaries after combination therapies with metformin and fenugreek seed extract.¹⁶

Wellness Works Options for Women with PCOS

A combination of myo- and d-chiro-inositol in the optimum 40:1 ratio combined with chromium, cinnamon and fenugreek is now available in one product from Wellness Works. The new Wellness Works Women’s Health line features PCOS Support (WW #10421), which provides all ingredients supported by studies in an easy-to-use capsule and a month supply per bottle. Wellness Works also offers vitamin D3 supplements in 1,000-5,000 IU options, dietary fiber supplementation with Colon Health Support (WW #10370) and several high-quality omega-3 supplements to help improve the nutritional status of PCOS patients.

View additional products in Wellness Works Women’s Health Line.

A version of this article originally appeared entirely in PCCA’s members-only magazine, the Apothagram.

References

1. CDC. (last reviewed 2022 30 December). PCOS (Polycystic Ovary Syndrome) and Diabetes. Accessed 03.01.2023 at https://www.cdc.gov/ diabetes/basics/pcos.html

2. Sirmans, S.M., Pate, K.A. (2013). Epidemiology, diagnosis, and management of polycystic ovary syndrome. Clinical epidemiology, 6, 1–13. Accessed 03.01.2023 at https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3872139

3. The Johns Hopkins University, Hospital and Health System. (2023, reviewed by Michos, E.D.) Polycystic Ovarian Syndrome: How Your Ovaries Can Affect Your Heart. Accessed 03.01.2023 at https://www.hopkinsmedicine.org/ health/conditions-and-diseases/polycystic-ovarian-syndrome-how-your-ovaries-can-affect-your-heart

4. Barry, J.A., Azizia, M.M., Hardiman, P.J. (2014). Risk of endometrial, ovarian and breast cancer in women with polycystic ovary syndrome: a systematic review and meta-analysis. Human reproduction update, 20(5), 748–758. Accessed 03.01.2023 at https://pubmed.ncbi.nlm.nih.gov/24688118

5. Woodward, A., Klonizakis, M., Broom, D. (2020). Exercise and Polycystic Ovary Syndrome. Advances in experimental medicine and biology, 1228, 123–136. Accessed 03.03.2023 at https://pubmed.ncbi.nlm.nih. gov/32342454

6. Perelman, D., Coghlan, N., Lamendola, C., Carter, S., Abbasi, F., McLaughlin, T. (2017). Substituting poly- and mono-unsaturated fat for dietary carbohydrate reduces hyperinsulinemia in women with polycystic ovary syndrome. Gynecol Endocrinol, 33(4), 324–327. Accessed 03.03.2023 at https://pubmed.ncbi.nlm.nih.gov/27910718

7. Soliman, G.A. (2019). Dietary Fiber, Atherosclerosis, and Cardiovascular Disease. Nutrients, 11(5), 1155. Accessed 03.03.2023 at https://pubmed. ncbi.nlm.nih.gov/31126110

8. Sorensen, L.B., Soe, M., Halkier, K.H., Stigsby, B., Astrup, A. (2012). Effects of increased dietary protein-to-carbohydrate ratios in women with polycystic ovary syndrome. Am J Clin Nutr. 95(1), 39–48. Accessed 03.03.2023 at https://pubmed.ncbi.nlm.nih.gov/22158730

9. ClinicalTrials.gov. (first posted 2009, last update posted 2017). Vitamin D for the Treatment of Women with Polycystic Ovary Syndrome (PCOS). Accessed 03.03.2023 at https://clinicaltrials.gov/ct2/show/NCT00907153

10. Kalra, B., Kalra, S., Sharma, J.B. (2016). The Inositols and Polycystic Ovary Syndrome. Indian J Endocrinol Metab., 20(5), 720-724. Accessed 03.03.2023 at https://pubmed.ncbi.nlm.nih.gov/27730087

11. Benelli, E., Del Ghianda, S., Di Cosmo, C., Tonacchera, M. (2016). A Combined Therapy with Myo-Inositol and D-Chiro-Inositol Improves Endocrine Parameters and Insulin Resistance in PCOS Young Overweight Women. Int J Endocrinol, 2016, 3204083. Accessed 03.03.2023 at https:// pubmed.ncbi.nlm.nih.gov/27493664

12. Unfer, V., Nestler, J.E., Kamenov, Z.A., Prapas, N., Facchinetti, F. (2016). Effects of Inositol(s) in Women with PCOS: A Systematic Review of Randomized Controlled Trials. Int J Endocrinol, 2016, 1849162. Accessed 03.03.2023 at https://pubmed.ncbi.nlm.nih.gov/27843451

13. Fazelian, S., Rouhani, M.H., Bank, S.S., Amani, R. (2017). Chromium supplementation and polycystic ovary syndrome: A systematic review and meta-analysis. J Trace Elem Med Biol, 42, 92–96. Accessed 03.03.2023 at https://pubmed.ncbi.nlm.nih.gov/28595797

14. Amooee, S., Parsanezhad, M.E., Ravanbod Shirazi, M., Alborzi, S., Samsami, A. (2013). Metformin versus chromium picolinate in clomiphene citrate-resistant patients with PCOs: A double-blind randomized clinical trial. Iran J Reprod Med, 11(8), 611–618. Accessed 03.03.2023 at https://pubmed. ncbi.nlm.nih.gov/24639797

15. Khan, A., Safdar, M., Ali Khan, M.M., Khattak, K.N., Anderson, R.A. (2003). Cinnamon Improves Glucose and Lipids of People With Type 2 Diabetes. Diabetes Care, 26 (12): 3215-3218. Accessed 03.03.2023 at https:// diabetesjournals.org/care/article/26/12/3215/21858/Cinnamon- Improves-Glucose-and-Lipids-of-People

16. Hassanzadeh Bashtian, M., Emami, S.A., Mousavifar, N., Esmaily, H.A., Mahmoudi, M., Mohammad Poor, A.H. (2013). Evaluation of Fenugreek (Trigonella foenum-graceum L.), Effects Seeds Extract on Insulin Resistance in Women with Polycystic Ovarian Syndrome. Iran J Pharma Resea, 12(2), 475–481. Accessed 03.03.2023 at https://pubmed.ncbi.nlm.nih.gov/24250624

PCOS: More than Insulin Resistance

Wed, 09 Sep 2020 12:59:06 GMT

By Sara Hover, RPh, FAARM, PCCA Clinical Compounding Pharmacist

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of reproductive age world-wide.¹ The diagnostic criteria have changed over the last several years and vary a bit for adolescents.² Therapeutic options for PCOS include medication, achieving hormone balance and lifestyle management. Treatment goals address the most prominent symptoms, including hirsutism, infertility and acne as well other issues related to insulin resistance.¹ Recently, links have been made between PCOS, hypothyroidism,³ periodontal disease⁴ and low vitamin D levels.⁵

I covered hirsutism in my blog post “ An Innovative Option for Hirsutism: Topical Meformin ,” so here I will discuss other comorbidities that can be addressed to help this patient population. The complicated pathophysiology of PCOS, which intertwines epigenetics and environmental factors, has yet to be completely illuminated. Current treatment revolves around managing symptoms.

Hormone Balance

Women with PCOS have many anovulatory cycles resulting in lower progesterone production. This lack of progesterone production creates an imbalance between estrogen and progesterone, resulting in endometrial hyperplasia, a condition where the endometrium becomes excessively thick. Women with PCOS-induced endometrial hyperplasia are more likely than women without PCOS to develop endometrial carcinoma.⁶ Therefore, it is prudent to monitor hormone levels and create proper balance between estradiol and progesterone. Life is about balance, after all. There are some studies showing that women with PCOS have an insensitivity to progesterone associated with elevated fasting insulin.⁷ Therefore, reducing insulin levels will promote progesterone functionality. This is just another example of the intertwining of the systems of the body.

Insulin Resistance

Insulin resistance is the most prominent metabolic consequence for PCOS patients, affecting nearly 70% of this population. When the insulin receptor is unresponsive to insulin, higher amounts of this hormone are required to send the same message. This results in increased production and release of insulin. Hyperinsulinemia (abnormally high blood insulin level) and insulin resistance are both also seen in lean PCOS patients, not just obese patients.⁸ Excess insulin can contribute to excess androgen production by direct stimulation of the ovarian theca cells. Hyperinsulinemia also leads to higher free testosterone by suppressing sex hormone binding globulin.⁹ Treating insulin resistance with medication and lifestyle changes can therefore have an incredible impact on PCOS.

Metformin has emerged as the prominent treatment choice in PCOS to reduce insulin resistance and lower insulin levels. The major drawback with metformin is the gastrointestinal side effects with the oral dosage form, including diarrhea, nausea, indigestion and abdominal pain.¹⁰ An alternative delivery method to avoid the stomach would be permeation-enhanced topical or vaginal administration. Pharmacy compounding may be a good choice in these instances where patients need customized medication options in various dosage forms.

Hypothyroidism

Subclinical hypothyroidism is frequently detected in PCOS patients. One of the cross functions of thyroid hormones is to act as an insulin agonist in muscle tissue and insulin antagonist in the liver. Therefore, if thyroid hormone is low, there would be an effect on glucose utilization and production. Thyroid hormone replacement in PCOS patients may also lead to a reduction in serum androgen level. In fact, some authors have considered insulin resistance to result from hypothyroidism.³ It could be hypothesized that the increased rate of infertility in PCOS could also be linked to decreased thyroid hormones. Finding the right balance of thyroid hormones can be tricky, though. Custom formulations of T4 (levothyroxine sodium) and T3 (liothyronine) or porcine thyroid hormone provide another tool in the prescriber’s toolbox to meet individual patient needs, and this is another particular area where pharmacy compounding may be able to help.

Periodontal disease

A recent review correlated a link between PCOS and periodontal disease, which is a chronic inflammatory condition that can cause destruction of the tissue that surrounds teeth.⁴ The risk of PCOS patients developing periodontal disease is inconclusive, but it is worth it for practitioners to be aware of the correlation. Dentists should be aware and monitor their patients for possible PCOS, and practitioners treating PCOS should question patients on their dental health. There are several dental preparations that can reduce gum inflammation and promote healing for gingival disease.

Vitamin D3

The relationship between vitamin D and PCOS is controversial but interesting. Current literature recognizes that Vitamin D is a hormone and is instrumental in immune system function while playing a role with certain disease states, such as Type 2 diabetes, cardiovascular disease and cancer. ^5,11 An underlying issue of all those disease states as well as PCOS is inflammation. Vitamin D has shown to inhibit the release of inflammatory cytokines, thereby reducing inflammation. Many observational studies have demonstrated that PCOS patients with a low vitamin D level had increases in body mass index, insulin resistance, testosterone and dehydroepiandrosterone.⁵ This information provides an opportunity for pharmacists to educate patients while providing a quality vitamin D3 supplement. Working with patients and providers to optimize vitamin D3 levels may therefore play a critical role in helping PCOS patients.

Many of the potential treatment options I’ve discussed in this article are specifically relevant to pharmacy compounding. Balancing hormones, compounding prescriptions in alternative dosage forms when commercial products do not meet patient needs, and helping them achieve optimal nutrition and lifestyle choices are all advantages of prescribers and patients working closely with compounding pharmacists. Pharmacies looking for supplements to offer their patients might consider Wellness Works, which carries professional-grade vitamin D3 softgels (5,000 IU). PCCA members with Clinical Services access can also find some examples of commonly requested compounding formulas in our database that may be relevant to discuss with practitioners concerning these patients. If they have questions about compounding for patients with PCOS, they can contact our clinical compounding pharmacists at 800.331.2498.

Sara Hover, RPh, FAARM, has been a compounding pharmacist for over 20 years and joined the PCCA Clinical Services team in June 2013. Before joining the PCCA staff, she was the owner and pharmacist of Creative Compounds in Prosper, Texas, an independent, compounding-only pharmacy that focused on women’s health and nutrition. In addition to her expertise in hormone replacement therapy, Sara possesses a vast knowledge of homeopathics as well as herbal and vitamin supplements. Sara obtained her Bachelor of Science degree from the University of Texas at Austin in 1994. She is a lifetime member of the University of Texas College of Pharmacy Alumni Association.

Photo by Clarisse Meyer on Unsplash.

References

1. Witchel, S. F., Oberfield, S. E., & Peña, A. S. (2019). Polycystic ovary syndrome: Pathophysiology, presentation, and treatment with emphasis on adolescent girls. Journal of the Endocrine Society, 3 (8), 1545–1573. https://doi.org/10.1210/js.2019-00078

2. Tehrani, F. R., & Amiri, M. (2019). Polycystic ovary syndrome in adolescents: Challenges in diagnosis and treatment.International Journal of Endocrinology & Metabolism, 17(3). https://dx.doi.org/10.5812%2Fijem.91554

3. Fatima, M., Amjad, S., Ali, H. S., Sr., Ahmed, T., Kahn, S., Raza, M., & Inam, M. (2020). Correlation of subclinical hypothyroidism with polycystic ovary syndrome (PCOS). Cureus, 12(5). https://dx.doi.org/10.7759%2Fcureus.8142

4. Machado, V., Escalda, C., Proença, L., Mendes, J. J., & Botelho, J. Is there a bidirectional association between polycystic ovarian syndrome and periodontitis? A systematic review and meta-analysis. Journal of Clinical Medicine, 9(6). https://dx.doi.org/10.3390%2Fjcm9061961

5. Wang, L., Lv, S., Li, F., Yu, X., Bai, E., & Yang, X. (2020). Vitamin D deficiency is associated with metabolic risk factors in women with polycystic ovary syndrome: A cross-sectional study in Shaanxi China. Frontiers in Endocrinology, 11. https://dx.doi.org/10.3389%2Ffendo.2020.00171

6. Li, X., Feng, Y., Lin, J.-F., Billig, H., & Shao, R. (2014). Endometrial progesterone resistance and PCOS. Journal of Biomedical Science, 21(1). https://dx.doi.org/10.1186%2F1423-0127-21-2

7. Blank, S. K., McCartney, C. R., Chhabra, S., Helm, K. D., Eagleson, C. A., Chang, R. J., & Marshall, J. C. (2009). Modulation of gonadotropin-releasing hormone pulse generator sensitivity to progesterone inhibition in hyperandrogenic adolescent girls — Implications for regulation of pubertal maturation.The Journal of Clinical Endocrinology & Metabolism, 94(7), 2360–2366. https://doi.org/10.1210/jc.2008-2606

8. Sanchez-Garrido, M. A., & Tena-Sempere, M. (2020). Metabolic dysfunction in polycystic ovary syndrome: Pathogenic role of androgen excess and potential therapeutic strategies. Molecular Metabolism, 35. https://doi.org/10.1016/j.molmet.2020.01.001

9. Marshall, J. C., & Dunaif, A. (2012). Should all women with PCOS be treated for insulin resistance? Fertility and Sterility, 97(1), 18–22. https://doi.org/10.1016/j.fertnstert.2011.11.036

10. Metformin. (2020). In Clinical Pharmacology. Retrieved from http://clinicalpharmacology-ip.com/Forms/drugoptions.aspx?cpnum=379&t=0

11. Norman, A. W. (2008). From vitamin D to hormone D: Fundamentals of the vitamin D endocrine system essential for good health. The American Journal of Clinical Nutrition, 88(2), 491S–499S. https://doi.org/10.1093/ajcn/88.2.491S

These statements are provided for educational purposes only. They have not been evaluated by the Food and Drug Administration, and are not to be interpreted as a promise, guarantee or claim of therapeutic efficacy or safety. The references cited did not necessarily evaluate PCCA products or formulas included in these statements. The information contained herein is not intended to replace or substitute for conventional medical care, or encourage its abandonment.