What is PCOS and TCM?
Polycystic ovary syndrome (PCOS) is a complex condition characterized by elevated androgen levels, menstrual irregularities, and/or small cysts on one or both ovaries. Alternative medicine such as Traditional Chinese Medicine(TCM) have been shown to be effective in treating women with PCOS to successful conception.
How prevalent is PCOS worldwide?
According to the National Institutes of Health Office of Disease Prevention, PCOS affects approximately 5 million women of childbearing age in the U.S. Costs to the U.S. health care system for the identification and management of PCOS are approximately $4 billion per year.
Research suggests that 5% to 10% of females 18 to 44 years of age are affected by PCOS, making it the most common endocrine abnormality among women of reproductive age in the U.S. 
What is polycystic?
The term polycystic ovaries refers to ovaries that contain 10 or more immature follicles with a maximum 9 mm diameter and whose central connective tissue is increased. Under ultrasound, multiple antral follicles— without a dominant follicle—and, as a whole, clearly enlarged ovaries are detected. The follicles fail to mature into a tertiary follicle ready for ovulation. Ovulation fails to take place and menstrual periods are accordingly irregular or absent.
What causes PCOS?
The pathophysiology of PCOS involves primary defects in the hypothalamic–pituitary axis, insulin secretion and action, and ovarian function. Although the cause of PCOS is unknown, PCOS has been linked to insulin resistance and obesity. The association with insulin function is expected; insulin helps to regulate ovarian function, and the ovaries respond to excess insulin by producing androgens, which can lead to anovulation. 
What are the symptoms of PCOS?
Clinical signs of PCOS include elevated luteinizing hormone (LH) and gonadotropin–releasing hormone (GnRH) levels, whereas follicular-stimulating hormone (FSH) levels are muted or unchanged. As a result of the increase in GnRH, stimulation of the ovarian thecal cells, in turn, produces more androgens. 
Usually PCOS patients present with the following:
● enlarged ovaries with numerous small cysts,
● irregular menstrual cycles,
● increased body hair in a typical male pattern (hirsutism)
● changes in the fat and carbohydrate metabolism (insulin resistance)
● hair loss
How is PCOS treated by Conventional Medicine?
Treatment goals include correcting anovulation, inhibiting the action of androgens on target tissues, and reducing insulin resistance.
As the first step, the pituitary gland and ovarian functions are temporarily suppressed by means of oral ovulatory inhibitors, that is, the “pill.” In this context, antiandrogen progestagens are preferred.
The excess weight must be reduced in order to lower the elevated estrogen levels and therefore also the rise in LH secretion that was caused by the increase in fat tissue.
In patients with a diabetic metabolism, oral anti-diabetic drugs can be prescribed as well, to lower insulin resistance.
To assist in the promotion of fertility, the following are indicated:
● as a rule, gonadotropins in low dosage after so called down regulation
● in appropriate cases, ovarian stimulation with Clomiphene (e.g., indication: ovulatory disturbances)
● surgical drilling and thereby destruction of excess antral follicles (exception)
● in ovarian overreaction to the stimulation: in vitro fertilization (IVF)
Other drugs include Metformin, Human menopausal gonadotropin (HMG), FSH and Letrozole.
The Pill, Metformin and Clomiphene Effects (in detail)
The oral contraceptive pill (OCP) is believed to be more effective than insulin-sensitizing drugs in improving menstrual pattern and reducing serum androgen levels.
On the other hand, metformin, an insulinsensitizing drug (ISD), is found to be more effective than the OCP in reducing fasting insulin levels and not increasing triglyceride levels.
Metformin alone or in combination with clomiphene, is found to increase ovulation in women with PCOS and may reduce health risks from insulin resistance and the effect of abnormal levels of androgen. However, the possible adverse effects from using metformin could include nausea and vomiting .
The link between Sugar, Insulin and PCOS
1. Sugar -> Higher levels of Insulin -> PCOS
Epidemiological studies have found that women with PCOS have an increased risk for metabolic syndrome, including central obesity, insulin resistance, hyperinsulinemia(high levels of insulin), impaired glucose intolerance, and type 2 diabetes. This brings up a very important mutual relationship between the two syndromes: PCOS women have a higher prevalence of metabolic syndrome and women with metabolic syndrome commonly show the reproductive and endocrine traits of PCOS. Thus, PCOS, obesity, and insulin resistance are frequently associated.
It has also been found that insulin resistance, a core component of metabolic syndrome, is believed to play a crucial role in PCOS pathogenesis and is present in up to 80% of women with PCOS .
2. High levels of Insulin increase testosterone levels
Hyperinsulinemia contributes to hyperandrogenemia(elevated levels of androgens) by disrupting the hypothalamic-pituitary-ovarian axis. More speciﬁcally, insulin is observed to have a synergistic effect with luteinizing hormone to initiate the steroidogenic pathway and testosterone production by ovarian theca cells. Basically it means testosterone production is increased with higher levels of insulin.
3. Insulin resistance affect ovulation
Insulin resistance and compensatory hyperinsulinemia may also affect ovulation in PCOS women. This may be due to the ability of insulin to increase the amplitude and frequency of release of gonadotropins, LH and follicle stimulating hormone (FSH)  and/or re-programming the way the ovary responds to these hormones generally identiﬁed as increased LH/FSH ratios. Independently, hyperinsulinemia may affect ovulation by causing granulosa cell dysfunction and consequently delay or diminish follicle growth leading to follicular arrest .
4. Insulin resistance cause downregulation of sex hormone binding globulin(SHBG)
In addition, hepatic insulin resistance may cause downregulation of sex hormone binding globulin (SHBG) which plays an important role in binding testosterone. In PCOS women, low SHBG levels are a common clinical ﬁnding related to hyperandrogenism, which in turn increases bioactive testosterone by enhancing free androgens in blood circulation.
Therefore it is imperative to control your blood sugar levels and your sugar intake if you are a PCOS patient.
How does TCM treats PCOS
From the perspective of TCM, we can describe PCOS in terms of root vacuity (ben xu本虚) and tip repletion (biao shi标实).
The kidneys are responsible for reproductivity. Most patients with infertility suffer from kidney vacuity. According to TCM, the kidneys store essence (jing精); essence and blood (xue血) share the same source therefore treating them is important in treating PCOS.
A lack of essence and blood impairs the functions of the extraordinary vessels chong mai（冲脉） and ren mai（任脉）; under these conditions, it is difficult to become pregnant.
Kidney vacuity hence forms the basis, whence phlegm-dampness repletion, fire resulting from liver qi stagnation, or qi stagnation with blood stasis follow and facilitate each other.
Affected organs are the liver, spleen, and kidneys; the disturbance manifests in the chong mai and ren mai.
In TCM, PCOS is generally differentiated into the following syndromes:
● kidney vacuity
● liver fire
● qi stagnation with blood stasis
Treatment focuses primarily on replenishing kidney vacuity. To complement this, we have to:
● strengthen the function of the spleen, to regulate qi and transform phlegm
● soothe liver qi, to resolve stagnation and reduce fire
● invigorate blood, to resolve the stasis and regulate menstruation
Both the PCOS treatment principle and the choice of TCM herbs follow this pattern differentiation in accordance with the presenting pathology. The goal of treatment is always to regulate menstruation. In this way, we can effectively treat an existing infertility.
Expressed in biomedical terms, a regular menstrual cycle stems from the correct cooperation of hypothalamus, hypophysis, and the ovaries. To regulate menstruation means here to regulate this connection (axis of reproduction).
What are the current research regarding TCM in PCOS?
PCOS is a complicated syndrome that appears to be closely associated with insulin resistance. Currently, there is no single drug that can treat both reproductive and metabolic aspects and all the clinical manifestations in between. Additionally, using hormonal therapy to treat hyperandrogenism is not without side effects and is not useful for women wishing to conceive.
Therefore, as an integrated part of Traditional Chinese Medicine(TCM) and a relatively safe treatment , acupuncture treatment for PCOS has gained increasing attention in recent years. The effect of acupuncture in treating PCOS is most likely mediated via activation of sensory nerve fibers, which in turn modulate the sympathetic activity to the ovaries and in the central nervous system [20, 21].
The following studies reflect some of the benefits of using TCM in PCOS:
1. Improve insulin sensitivity
A review found that acupuncture can correct various metabolic disorders contributing to the development of insulin resistance, such as hyperglycemia, overweight, hyperphagia, hyperlipidemia, inflammation, altered activity of the sympathetic nervous system, and insulin signal defect . Thus, acupuncture may have the potential to improve insulin sensitivity .
Other findings suggest that electrical acupuncture stimulation affects more functional signaling pathways related to insulin sensitivity, while manual stimulation of acupuncture needles has a greater effect on glucose tolerance . Furthermore, in female insulin-resistant rats both electrical and manual acupuncture stimulation enhances insulin sensitivity via activation of sensory afferents .
One prospective pilot study  of TCM acupuncture affecting the insulin sensitivity in 81 cases of women with PCOS with insulin resistance showed that acupuncture has a significant effect on improving the insulin sensitivity in these patients.
2. Alter neuroendocrinological status
In another study done, the sympathetic nerve function in the ovaries stemming from an alternation in the neuroendocrinological status could be regulated by therapy of repeated electroacupuncture to decrease endothelin-1 and nerve growth factor (NGF). In another research, TCM combined with Western Medicine utilized in clinical practice showed encouraging outcome on the women with PCOS and anovulation, but with no obvious adverse reactions. Lee, et al reported that two herbal formulae, Changbudodam Tang (Cangfu Daotan Decoction, 苍附导痰汤) and Yongdamsagan Tang (Longdan Xiegan Decoction, 龙胆泻肝汤), significantly downregulated the increased NGF staining in the ovaries without inﬂuencing the brain tissues signiﬁcantly.
3. Regulate menstrual frequency
TCM acupuncture and specifically low-frequency ElectroAcupuncture(EA) affect PCOS symptoms via modulation of endogenous regulatory systems, including the sympathetic nervous system, the endocrine system and the neuroendocrine system. In one study, 12 of 24 women with undefined ovulatory dysfunction treated with manual TCM acupuncture (average, 30 treatments) had marked improvements in menstruation and biphasic basal body temperature for more than two cycles or became pregnant. 
These studies demonstrate that low-frequency EA and TCM affects endocrine, neuroendocrine and metabolic disturbances in PCOS without any negative side-effects. Indeed, EA can be a suitable alternative or complement to pharmacological induction of ovulation.
How I treat PCOS with TCM?
For both Western and Chinese medicine the first line of treatment is diet and weight control. The goal is to regulate the blood sugar, decrease insulin resistance and improve glucose metabolism to stabilize mood and weight. With some women, reducing insulin levels and improving insulin sensitivity through weight loss, a low glycemic diet and exercise may restore normal ovulation.
TCM approach treats underlying imbalances causing hormonal irregularities to correct the problem and the symptoms together. Thorough evaluations, specialized acupuncture treatments, and nutritional guidelines are used to regulate the menstrual cycle.
For any treatment option, make sure to stick with your game plan since results can take a few months to appear. You’ll notice that cycles become more regular, indicated by mid-month vaginal discharge and elevated temperatures. Eventually, you’ll also see weight reduction and lesser abnormal hair growth.
Usually, patients don’t know they have PCOS until they start trying to conceive(TTC). At the very most, they just accept that they have irregular periods and it is a ‘norm’. I always mention to my TTC patients, their sole objective is to CONCEIVE, not to restore FSH/LH/Testosterone/Glucose levels to some optimum range. Blood serum levels fluctuate, i.e to say there will be months where you DO ovulate, the KEY is to know when you ovulate before trying. It is clinically impossible to ask patients to go for ultrasound scan every month to test for ovulation, therefore we recommend Body Basal Temperature(BBT) charting. Although it is not gold standard medically per se, it does help to map out your menstrual patterns.
After definite diagnosis, we will have to diagnose your body constitution. Not all PCOS patients are diagnosed with Kidney Deficiency or Dampness Body Constitution. Every individual is different, therefore every treatment approach is individualised.
After which, you will need chinese herbal medication, acupuncture and a customised diet/exercise plan.
Here are some tips to help yourself while waiting for your first consultation with us.
●Aim for at least 30 minutes of exercise each day. Note: this does not mean over-exercising. Balance is the key here and the goal is to gradually lose weight over time.
●Eat your leafy greens. If you already do, up the amount to 5 servings a day. What I mean is dark leafy greens like kale, kailan and broccoli.
●Eat low-glycemic carbs, like whole grains and vegetables. Avoid the white ones, like rice, bread, and starchy foods low in nutritional value. I recommend replacing your white rice with brown rice, and white bread with wholemeal wholegrain bread.
●Eat small meals and snacks at least every 3-5 hours to keep your blood sugar stable. Include things like hummus, nuts, and hard-boiled eggs for your snacks as they are great for you because they keep you full longer.
●Limit or avoid your dairy intake. If you do drink milk, you can choose plant-based milk such as almond milk and cashew milk.
●Try also adding probiotics and prebiotics into your daily routine. They’ll keep your intestinal tract clean and healthy to promote better digestion. This will in turn help with your insulin resistance.
Contact us to make an appointment if you have been diagnosed with PCOS or have problems with ovulation.
Edmund graduated with a First Class Hons in Biomedical Sciences and Traditional Chinese Medicine from Nanyang Technological University, before taking a Masters in Gynaecology(TCM) in Liaoning, China.
He has successfully treated patients with unexplained infertility, Polycystic Ovarian Syndrome(PCOS) and endometriosis and helped them conceive naturally with Traditional Chinese Medicine.
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