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Polycystic Ovarian syndrome Should be called polyfollicular, they

are not really ovarian cysts. 20% of the population have the

condition inherited. Possibly condition of survival, since

the calorie use is very efficient, also very efficient at storing calories; whole week of fasting might be needed to produce weight loss.

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PCOS a condition which consist of the presence of two out of the following three criteria, with the exclusion of other aetiologies

Oligo- and /or anovulation hyperandrogenism (clinical and /or biochemical) polycystic ovaries(ovary with 12 or more follicles,

measuring 2-9mm in diameter and or increased ovarian volume).

Although the number of cysts may be of less relevance than the volume of ovarian stroma, which correlate with serum testosterone concentrations.

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A women having polycystic ovaries in the absence of an ovulation disorder, or hyperandrogenism, should not be considered as having PCOS, although she may develop syndrome over time. E.g. if she gains weight.

Should be considered as complex endocrine disorder.

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Pathophysiology of PCOS Poorly understood Multifactorial Genetic link; father premature baldness. High incidence

in South Asian women.Also with type two diabetes. Environmental; nutrition, weight thyroid involvement metabolic syndrome; some suggest a genetic

susceptibility to insulin stimulation of androgen secretion, blocking follicular maturation. Seem to be that abnormal insulin response is the key underlying factor.

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Too many follicles, ovulatory and anovulatory.

In anovulatory PCOS follicles do not mature.

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Diabetes (NIDDM); increasingly common, as is PCOS.

Causes of insulin resistance; Associated with abdominal obesity, excessive intake of carbohydrates, lack of exercise, and stress..

Fitness a greater link than diet and obesity. Weight gain; worsening of symptoms

Some with ovulatory hyperandrogenism can present with normal insulin and glucose tolerance, indicating additional factors involved.

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symptoms

Acne, hirsutism, alopecia menstrual disturbance infertility obesity asymptomatic

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endocrinology

Increase fasting insulin, androgens (testosterone and DHEA-S), LH, oestradiol, and oestrone, prolactin while FSH low.

Progesterone low. Decreased SHBG the cycle of abnormalities tend to

be perpetuated.

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Elevated androgens Ovarian and adrenal production increased Possible due to hyperactive production of

CYP17 enzyme, responsible for forming androgens in ovaries and adrenals from DHEA-S.

Elevated testosterone correlates with elevated LH levels.

High androgens levels in ovary inhibit FSH, and therefore inhibit development and maturation of the follicles.

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Elevated DHEA due to stimulation by ACTH, produced by the pituitary in response to stress. Excess DHEA converts to androgens, contributing to elevated androgens.

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Skin and adipose tissue

Aromatase and 17betahydroxysteroid activities are increased in fat cells, and peripheral aromatisation increases with body weight.

Chronic hyper-estrogen production. Hirsutism incidence higher in USA in

women with PCOS, possibly due to genetically differences in 5-alpha-reductase activity, diet, exercise.

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Excessive adrenal androgen production; could be at puberty , or perhaps because of stress.

Androgen converted to oestrogen. Leading to increase LH, which leads to increase

ovarian androgen production, which could impair folliculogenesis, and so perpetuating the cycle.

Increased gonadotrophin releasing hormone, leading to pulsatile increase LH. FSH not increased due to negative feedback of elevated oestrogen.

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25% PCOS have elevated prolactin levels, resulting from elevated oestrogen feedback to pituitary gland, contributing to elevated oestrogen.

HPA axis weakened by chronic stress, insulin sensitivity heightened, adversely affecting the thyroid, and adrenals, excess cortisol, triggers elevated levels of prolactin and sympathetic nervous system response. Prolactin inhibits FSH, elevates LH.

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Chronic elevation of serum insulin levels associated with elevated androgen levels. High levels insulin, lowers presence of SHBG; increased amount of free androgen in serum.

Which stimulate the peripheral androgen receptors, resulting in an increase in 5-alpha reductase activity directly increasing the conversion of testosterone to the more potent dihydrotestosterone

Excess adipose tissue provides site for peripheral conversion of androgens.

Leading to elevated acyclic oestrogen, as well as increased pituitary sensitivity to GnRH

Insulin alters hormonal production; insulin and insulin like growth factor receptors are located in ovarian tissue.

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Long term problems Diabetes mellitus dyslipidaemia hypertension, and CVD endometrial (linked to weight obesity, and use of

OCP, nulliparity and infertility, hyperplasia of endometrium) however true risk difficulty to assess. Need at least bleed every three months.

breast cancer (also associated with obesity, hyperandrogenism, and infertility).

Not at risk of osteoporosis.

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Conventional treatment OCP; reduce androgens, increase SHBG. Combined

pill can worsen insulin resistance, so CI in obese. Hirsutism; antiandrogens, spironolactone; inhibiting

the binding of dihydrotestosterone to the receptors at the hair follicle.

Infertility; clomiphene, induces ovulation, acts by inhibiting oestrogen negative feedback at hypothalamus, enhance production FSH. laparoscopic ovarian surgery

Metformin. Weight loss

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Treatment

Break pattern hyperinsulinaemia, low refined carbohydrate diet.

Takes 6-9 months with drugs to improve hirsutism.

Shift in hormones needed might only be slight, oestrogen levels for PCOS tends to be within the normal ranges.

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Treatment PCOS Aims;

cyclic regularity fertility skin condition obesity insulin resistance, diet

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Weight loss; reduces androgens by interrupting

their cycle. Reduce conversion, so improve

ovulation rate. Increases SHBG reduces CVD reduces risk of diabetes 2 reduces endometrial hyperplasia

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phytoestrogens

Phytooestrogens and fibre; increase SHBG compete with endogenous

oestrogen. Reduce hypertrophy cholesterol clearance, and

oestrogen clearance affect the glucose tolerance.

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Glycyrrhiza glabra Glycyrrhetinic acid

inhibits 17beta-Hydroxysteriod dehydrogenase (converts androstenedione to testosterone). Which is active in the hair follicle, ovaries

reduced production of testosterone by ovaries (not adrenals).

Inhibits 11Beta-Hydroxysteroid dehydrogenase result in decreased conversion of cortisol to

cortisone, and the state of apparent mineral corticoids excess.

Elevated 11Beta-Hydroxydehydrogenase is responsible for androgen excess, because of the effect of insulin resistance on this enzyme

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Paeony lactiflora

Paeoniflorin (monoterpene glycoside)

act on ovary to reduce production of androgens in dose dependent manner.

Increase activity of aromatase promoting the syntheses of oestradiol from testosterone.

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May improve progesterone levels by normalising ovarian function when the activity of aromatase is inhibited.

aromatase is important in follicular maturation, ovulation and corpus luteum function, steroid hormone synthesis, and regulation conversion of androgens. The biofeedback in the pituitary gland and hypothalamus rely on aromatase to regulate prolactin and GnRH.

Modulates oestrogens and prolactin

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Paeony formulas improved ovulation

combined with angelica sinensis improved fertility.

Used the whole month.

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Combination with liquorice reduced testosterone levels and improves oestradiol to testosterone rations after 4 weeks of administration

pregnancy rates improve. Stimulates pituitary dopamine receptors, and

due to that after prolonged used LH, to FSH ration is significantly lower.

Dose equal amounts 7.5 g total. (25 ml each FE.

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Other hormonal herbs

Humulus; reduces LH via possibly anti gonadotropic effect.

Cimicifuga reduces pulsatile LH release serenoa repens; reduces the conversion

of testosterone to DHT via weak inhibition of 5Alpha reductase, and inhibits the binding of DHT at cellular binding sites.

Smilax spp; may competitive inhibit androgens.

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Long-term use of glycyrrhiza and smilax reduced hirsutism, (level androgen do not always reflect symptoms or not) might have increased androgen sensitivity, which might

be related to activity of 5 alpha reductase, this could be inherited.

changes in hair growth slow, at least 6-9 months. Changes seen in thickness, reduced growth rate of hair,

reduced frequency of waxing or other hair removal. Fennel externally spearmint internally reported to have made a change to

hirsutism.

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Panax and Eleutherococcus; normalising impaired glucose tolerance,

Panax normalised lipid profiles. Nervines; for normalising androgens when

they are elevated due to stress, and effect on HPO axis, if affected during stress.

Steroidal saponins containing herbs to help with the HPO axis, and stimulate ovulation. For the whole month or just follicular phase day 4-14.

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Vitex agnus castus

Hyperprolactinemia is related to adrenal stress and hyperinsulinemia in PCOS

needs to be given at least 3-6 months.

1-4 ml per day of a 1:2

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Caulophyllum thalictroides Traditionally used for

amenorrhoea, and profuse menstruation.

Useful to bring on menses. Dose 1.5-3 ml of 1:2 per day 30ml per week

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Insulin resistance

Galega officinalis; galegine potentiates the effect of insulin ( was used as model for chemical antidiabetic drug).

Trigonella foecum-graecum; powdered seed would include the soluble fibre, however tincture has shown to improve glycaemic control in patients with NIDDM, 6 ml/1:2 per day.

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Fibre; delay absorption of glucose, possibly by delaying gastric emptying. E.G. psyllium husks 5 g per meal, fasting plasma glucose, total and LDL cholesterol, and triglycerides reduced, and HDL cholesterol increased.

Aloe vera juice reduced blood glucose and triglycerides levels.

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Glycyrrhiza glabra; the flavonoids shown inhibitory action of aldose reductase (AR) inhibitors, which when blood glucose is raised , the polyol pathway, which is catalysed by the enzyme AR) can become activated in tissues which contain this pathway (lens, liver, kidney, Schwann cells), this leads to accumulation of the sugars sorbital, and dulcitol, which is toxic in excess, leading e.g. to cataract.

Evening Primrose oil, or the GLA also helped with the complications of diabetic neuropathy, possibly by affecting the myelin fat abnormalities.

Damage small capillaries; Vaccinium, Ginkgo.

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Gymnema when applied to mouth anaesthetising the sweet taste buds. Wears of after one or two hours,

extracts in Japan sold for control of obesity. rise in insulin levels towards normal, and number of beta cells in

pancreas increased. Weight loss; gymnema decreased weight gain, and food intake

in rats. Insulin dependent patient reduced insulin intake by 50% when

taking 8g of the dried herb. Lowered fasting blood glucose level by 35%, and glycosylated haemoglobin levels (a measure of long term blood sugar levels) significantly by the 6 to 8 months but sill higher then normal. Cholesterol reduced to near normal, and triglycerides were lowered, treatment period, was 6 to 30 months. .

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Gymnema in NIDDM; fasting blood glucose and glycosylated haemoglobin significantly reduced. Cholesterol and triglycerides also reduced. Fasting and post meal serum insulin increased. And most of the patient were able to reduce intake of drugs, and some totally and kept on gymnema alone.

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Disrupting sugar transport in the small intestine, and retards sugar absorption. Leading to reduction in peak blood sugar levels and better glycaemic control.

Long term trophorestorative effect on pancreatic beta cells.

Effective for reactive hypoglyaemia, and sugar craving, doses can be much lower than when treating diabetes.

Trials have used 400mg per day of extract; 8g of dried herb a day.

3.5-11 ml of 1:1 (10-33ml of 1:3 per day)

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Abnormal uterine bleeding Benign; organic; systemic health problems (e.g.

von willebrands disease, thrombocetopenia, hypothyroidism, liver disease, abnormal pregnancy, foreign bodies, trauma, infections, fibroids, polyps, adenomyosis, endometriosis (not usually heavy bleeding), cervicitis, uterine infections, IUD.

Malignant; cancer

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Menorrhagia

Pelvic congestion, capillary fragility, blood disorders, PID, oestrogen excessThyroidpoor liverpregnancy, miscarriage.adenomyosis, endometriosis, fibroids, functional menorhagia, IUD. Unoposed bleeding; Common premenopausal, and menarche.PCOS, hyperprolactinaemia, stress, obesity, weight loss.

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Menorrhagia; if saturating a super tampon or heavy pad more then than every hour for 6-8 hours or more.

If saturating pads every half hour or less; need intervention.

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Capsella bursa pastoris; antihaemorrhagic and astringent.

Used by eclectics for benign abdominal tumours

in WW1 used as replacement for ergot, to stop uterine bleeding (fungus that can grow on rye, ergot was used to induce contractions during labour, and to treat post partum haemorrhage.

In vitro extracts shown that it accelerates coagulation of blood.

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Achillea millefolium;astringent and haemorrhagic, tonic to circulatory system.

Used for menstrual irregularities, menorrhagia and metrorrhagia. Greeks used it for wounds American Indians to treat heamorrhagia physiomedicalist; diffusive vasostimulant, especially pelvic organs

and its circulation. Use for pelvic congestion, reduce uterine flooding, pain due to

engorged pelvic veins. Reduces clotting time in vivo. In vitro accelerates coagulation of blood. Flavonoids; decreases capillaries fragility.

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Alchemilla vulgaris

Astringent, antihaemorrhagic, antiinflammatory

used for diarrhoea and uterine bleeding

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Hydrastis, trillium uterine tonics and emmenagogues affect the

uterine tone (smooth muscle ; rubus, angelica sinsensis, caulophyllum, chamealerium luteum, Mitchella, cinnamomum)

soy and flax products iron, vit A, B complex, cholorophyl for vitamin K, vit

C., bioflavonoids, e.g. floradix Vitex agnus castus, Zingiber, Geranium maculatum

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Fibroids

Benign tumour in uterus, within uterine lining (intramural), towards the cavity (submucosal), or towards outer surface (subserous).

Increased growth with increased oestrogen (pregnancy, OCP)

shrink after menopause asymptomatic, menorrhage, dysparunia,

dysmenorrhoea, lower back pain, congestion. Complication; pressure on urinary tract, leading

to obstruction, urinary frequency, miscarriage.

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treatment

Inhibit growth. Diet; excess oestrogen avoidance,

organic, phytoestrogens, fruit,vegetables

stop bleeding. Weight loss Vit E Peaony lactiflora

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Thuja; by eclectics used for abnormal growths, tumours, cancers.

Traditional literature; retard growth of tumours,

astringent Castor oil pack.

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endometriosis

Endometrial tissue growth outside uterus

40% of those women have fertility issues. And 30% infertile because of it due to hormone imbalance, scarring

due to inflammation, immunological factors.

cyst on ovary; chocolate cyst, adhesions leading to dysparunia.

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Anti inflammatories

Turmeric Boswelia Cimicifuga racemosa

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Angelica sinensis

Enrich blood, stimulate circulation, relieve pain especially when congestion, regulate menstruation.

Anti-inflammatory;due to inhibition of the synthesis of prostaglandin. Inhibits synthesis thromboxane A2 in vitro, which may partly explain effect on circulation.

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Other herbs and supplements Antihaemorrhagic,anti-

inflammatory, vulnerary, lymphatic (calendula officinalis).

Fish oils, or other omega 3 work on oestrogen excess,

elimination, diet.

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Dysmennorhea

Spasmodic; more in young women, related to ischaemia or uterus or cervix. Pain with onset of bleeding.

Congestive; older women, may be associated with pathologies. Dragging sensation.

Severe in PID, and endometriosis, adenomyosis (typical over 40)

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Prostaglandins may play a role; Exercise,

Zingiber officinalis inhibits prostaglandins.

Achillea millefolium, Tanacetum parthenium.

Mg, Essential fatty acids

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Viburnum prunifolium

Caprifoliaceae bark is used. Native American, physiomedicalist;

viburnum opulus and prunifolium used for dysmennorhoea

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Traditional used for dysmenorrhoea, false labour pains, threatened miscarriage and asthma.

Folk use as a contraceptive and treatment of morning sickness have also been recorded.

Uterine sedative, bronchospasmolytic, hypotensive, astringent.

S.E Nausea and vomiting may occur with large doses.

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Cook; vib op primarily antispasmodic, acting on the nervous system, vib prun. More useful as uterine tonic for uterine weakness, prolapse, leukorrhoea, passive bleeding,

Felter felt that vib prun one of the most important uterine tonic.

Vib prun contains salicin, salicylic acid, arbutin, scopoletin (a coumarin also found in Angelica sinensis) which vib op does not have, flavonoids (amentoflavone), iridoid glycosides, triterpenes, and triterpenic acids.

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For dysmenorrhoea need to give a good dose; 2-5 ml per day of a 1:2.

The use of antispasmodics may be CI in gastric and enteric poisoning cases.

Presence of oxalate and oxalic acid; oxalate as the potassium or calcium salt present in many plants and calcium oxalate practically insoluble in water, unlikely to be present in aqueous ethanolic liquid extract in sufficient quantities to justify a precaution.

Scopoletin (coumarin)plant coumarins are unlikely to increase the risk of bleeding.

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Coumarin has an anticoagulant activity that is 1000x less then dicoumarol, because it lacks a 4-hydroxy group in its chemical structure, dicoumarol is formed from coumarol by bacterial action in damaged hay, properly dried plants does not contain dicoumarol and has no anticoagulant activity.There is not evidence that normal coumarins found in common plant and not altered by bacteria have any anticoagulant activity.

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Paeony with glycyrrhiza has antispasmodic properties. Also used with Angelica sinensis.

Anenome pulsatilla; antispasmodic, sedative, central nervous system depressant, emmenagogue.

Valeriana officinalis if real bad, Belladonna fol.

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Pelvic inflammatory disease Leading to adhesions, or abscesses,

and can lead to infertility. Check out what organism, need to

clear infection, antibiotics might be needed, refer.

Uterine antiseptics; thymus vulgaris, Hydrastis canadensis, Echinaceae purp and ang., Thuja occidentalis.

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Amenorhoea;

Premature ovarian failure hyperprolactinaeima, reduced FSH,LH as caused by

stress,weight loss eg excessive exercise, anorexia, genetic

anovulation with normal FSH, LH ; follicles not mature as in PCOD, progesterone deficiency.

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Diet make sure enough fat, and cholesterol, e.g. some animal products.

Vitex agnus castus Cimicifuga racemosa, Uterine stimulants; Mitchella, achillea,

Artemesia vulgaris, Caulophyllum thalictroides

phytoestrogens, soy, flax, Trifolium, Glycyrrhiza

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Vaginal discharge

Normal white discharge, about teaspoon per day

infections; candida vaginalis (Cottage cheese like discharge), trichomonias (fishy smell, green, yellow frothy), bacterial vaginosis.

check out diabetes, medications, oral contraceptives, antibiotics, tampon.

pessaries with calendula, teatree, thymus linalool when infection.

Yoghurt, or cider vinegar (2 tablespoons to pints)

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Vaginitis

Candida albicans (DD metabolic, or immune compromised, underlying cause when recurrent)

trichomonas vaginalis (discharge frothy, bubbly, yellow green, and itching, dysparunia, dysuria, occasional abodimial pain.

bacterial vaginosis (gardnerella vaginalis, thin, frothy, grey, odorous discharge

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Partner, safe sex clothing, loose allergie? Probiotics; vaginal microflora, feminine

hygiene products, lubricant, semen. Avoid sugar, alcohol, and have yogurts. Vit E externally less irritated, Garlic, Hydrastis, Berberis vulgaris,

Teatree,

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Fibrocystic breast disease Aggrevated by relative excess oestrogen, worse before period. Increases risk breast cancer hormone balancing plus lymphatics, circulation avoid coffee vit A, E, Evening Primrose Oil Iodine (mechanism not known, iodine in terminal and

interlobular duct cells, which are the cells involved in cystic changes, without iodine tissue more sensitive to oestrogen stimulation, which leads to produce mycrocyst high in potassium, an irritant producing fibrosis, and cyst isolation).

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Cervical dysplasia

Abnormal development of cervical cells, if untreated may lead to cancer.

Related to sexual partners,early sexual experience, genital herpes, or warts.

CIN I mild dysplasia CIN II moderate CINIII severe/ preinvasive carcinoma

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Pap I normal Pap II atypical cells Pap III moderate dysplasia Pap IV strongly suspicious, severe

dysplasia Pap V malignancy; invasive cancer

cells.

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Diet high in fruits and vegetables, for the flavonoids, carotenes, alpha carotene, lutein,

cryptoxanthinlycopene, xanthein; tomatoes, carrots, vit A, vit C, folic aid.

smoking; negative effect. Tarax rad, Hydrastis canadensis, Thuja occidentalis,

Echinacea angustifolia, Turmeric, Glycyrrhiza glabra. Douche; or pessaries with calendula

Calendula officinalis. Viola odorata