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Polycystic Ovarian Syndrome or Not?

Irregular periods, acne, hair loss, fatigue, weight gain, sluggish metabolism, at first glance these symptoms seem to point to PCOS. However, blood tests show a different story, in PCOS you would expect to see high androgen levels (testosterone, DHEAs) but this patient has low testosterone, low DHEAs, low estradiol and here’s the kicker – high cortisol! Her doctor had refused to do the cortisol testing which ultimately provided the solution to the puzzle of her symptoms which she has complained to her doctor about for years. It still remains to investigate why her cortisol is elevated. There are herbs that can be used to lower cortisol, but we’ll refrain from that until we can collect more data on why it’s elevated.

It’s easy in medicine to make assumptions and jump to conclusions, but this patient is a perfect example of why doing our due diligence and thoroughly investigating through diagnostic testing is important.

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Your Hormone Levels are “Fine” (Not!)

Many of the women that I see every day feel like there is a problem with their hormones, however, they’ve been to their family doctor who has told them that their hormone levels are “fine”. These women are suffering from infertility, hair loss, irregular periods, excessive facial or body hair, acne, peri-menopause, mood swings, low libido and PCOS, all of which are fairly obvious signs of hormone imbalance.

Here’s why you may be told that your hormones are “fine” when they’re actually not:
1. Countless patients haven’t even had the tip of the iceberg measured when it comes to their hormones. They’ve been trying to conceive for 3 years, yet no one has ever thoroughly measured their hormones. They’ve never had testosterone, DHEAs, androstenedione, and DHT measured. These are all hormones that can impact fertility.
2. Hormones vary from day to day and certain ones are really only clinically relevant at certain points of the menstrual cycle, but no one specified what day to have them measured. LH, FSH and estradiol should be measured on day 3 of a menstrual cycle. Progesterone should be measured 7 days post ovulation. If there is a hormone related problem, the relevant hormones should probably be measured more than once to confirm if they’re normal or not.
3. Hormone “normal” ranges are actually “abnormal” ranges. The lab ranges for hormones are particularly unreliable as indicators of good hormonal health. As a lab insider (I worked in one for 20 years), I know how normal ranges are set. Lab technologists average the results from a given number of samples and the average of those samples becomes the “normal” range. The problem with this is that doctors only order hormone blood work from people with a hormone related condition like infertility, hair loss, irregular periods, excessive facial or body hair, acne, peri-menopause, mood swings, and low libido. So if you average the results of an abnormal population and then call that your normal range, what you’ve actually got is an “abnormal range” and abnormal people will fit nicely into it so that their results look “normal” even though they clearly have a hormone related problem.

When I’m looking a patient’s blood work, I use my own optimal range, rather than the lab’s abnormal range to interpret whether the hormone blood tests are normal or not. I also like to see thorough hormone blood work and have it done at specific points in the menstrual cycle.

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Hypothyroid and Autoimmunity

If you’ve been diagnosed with an underactive thyroid, you may also have been tested to determine if your thyroid is underactive because you have a condition called Hashimoto’s disease. Hashimoto’s is an autoimmune thyroid problem where your body is attacking your thyroid and destroying the tissue so that it can’t function normally. Firstly, it’s important to know if this is the type of hypothyroidism that you have. The blood tests for Hashimoto’s include: TSH, free T3, free T4, anti-TPO antibodies, anti-thyroglobulin antibodies and anti-microsomal antibodies.

If these tests are positive for Hashimoto’s, then there are six factors that need to be considered in order to reduce the antibodies and help you feel better, maybe even recovering normal thyroid function.

1. Stress
2. Adrenal gland function
3. Viruses or latent viral infections (such as herpes viruses)
4. Diet
5. Dysbiosis and Leaky gut
6. Toxin accumulation (including heavy metals)

If you have been diagnosed with an underactive thyroid, particularly if there is a family history of hypothyroidism and if you are not feeling significantly better on thyroid medication, you should pursue Hashimoto’s testing and if positive, address the above factors with the assistance of a licensed naturopathic doctor.

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Fibroids and Estrogen

There are a couple of prevailing theories as to what causes fibroids. One, is that there is too much estrogen which is promoting proliferation of the uterine lining.

I saw an excellent example of this recently where we actually confirmed by blood test that the day 3 estrogen level was about 3 times the norm for that specific day of the cycle. The range for the follicular phase of the menstrual cycle (roughly day 1 to day 14) is 46-622 pmol/L. Because estrogen is at its lowest around day 1 of the period, and it increases to a peak at day 14, on day 3 you would expect estrogen to still be at the lower end of this range. The higher number would occur closer to day 12. This particular woman’s estrogen was already close to 500 on day 3. Ideally, estradiol measured on day 3 should be around 110 – 200 pmol/L. Random estradiol measurements that don’t take into account where exactly the person is in their cycle are fairly useless and will almost invariably be interpreted as “normal”.

What kind of symptoms would this cause?
1. Heavy menstrual bleeding. With this much estrogen so early in the cycle, there is a thick uterine lining being built, which means a lot of blood to discharge at her next period.
2. Painful periods. Excessive estrogen can promote inflammation and cramping.
3. Fibroids. Inflammation and estrogen are considered to be contributors to fibroids and with this much estrogen she’s got both going on.

The solution?
Provide specific nutrients that help the liver detoxify and eliminate excess estrogen. This particular person has already seen significant improvement in only 3 weeks of this type of treatment.

Source:
Hum Reprod Update. 2014 Sep 8. pii: dmu048. Ovarian steroids, stem cells and uterine leiomyoma: therapeutic implications. Moravek MB1, Yin P1, Ono M1, Coon V JS1, Dyson MT1, Navarro A1, Marsh EE1, Chakravarti D1, Kim JJ1, Wei JJ2, Bulun SE3.

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Polycystic Ovarian Syndrome Theories

Some of the prevailing theories as to what is going on with women with PCOS include:

1.  A defect in insulin action and secretion that leads to higher blood insulin levels and insulin resistance.
2.  A defect in the nervous and endocrine systems leading to an exaggerated LH (luteinizing hormone) pulse frequency and amplitude
3.  A defect of androgen (male hormone) production that results in enhanced ovarian testosterone, DHEAs and/or androstenedione production
4. An alteration in cortisol metabolism resulting in enhanced adrenal androgen production (Tasoula et al, Clin Endocrinol, 2004)
5. Intrinsic theca (ovarian) cell hypersensitivity to LH stimulation that results from defective inhibition by FSH that may involve inhibin-B signalling. (Hirshfeld-Cytron et al, J Clin Endocrinol Metab, 2009)

In any case, improvement is usually seen through measures that lower insulin such as low glycemic index, low glycemic load diet, stress reduction and daily exercise. Additional support from insulin sensitizing agents like inositol, NAC, zinc, and cinnamon is also helpful.

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What is a Normal Testosterone Level for a Woman?

Testosterone helps build muscle mass, helps maintain healthy vaginal tissue, provides energy, drive and motivation and influences libido in women. Too much testosterone can contribute to hair loss, acne, irregular periods and excess facial hair. So you want some testosterone, just not too much.

According to our lab, less than 2.0 nmol/L is normal for an adult female. Many of the patients that we test for testosterone come back either too high or too low. Being close to either end of the normal range can cause problems. Ideally, a woman’s testosterone level should be around 1.0 – 1.6 nmol/L, neither to close to the low or the high end.