Clinical

Phytotherapy for Polycystic Ovarian Syndrome

BY SAMANTHA BULLOCH

Polycystic ovarian syndrome (also known as polycystic ovary syndrome, PCOS) is a complex metabolic disease process involving one or more of the following organ systems: pancreas, hypothalamic-pituitary-ovarian axis, adrenals and thyroid. It is the most prevalent endocrinopathy in premenopausal women. A 2002 US estimate has PCOS affecting as many as 10% of a companys female workforce.1 Women suffering from PCOS are at a far higher risk of developing cardiovascular disease, hypertension, altered lipoprotein profiles, non-insulin-dependent diabetes, impaired glucose tolerance, endometrial hyperplasia, endometrial cancer, gestational diabetes or impaired glucose tolerance during pregnancy. In general PCOS responds favourably to comprehensive naturopathic care (a combination of herbal and nutritional medicine along with dietary and lifestyle support). Treatment is aimed at addressing both the causation and the symptoms and will differ depending on whether the patient/client is trying to conceive or not. While it is not possible to completely cure the disease, it is possible to gain significant symptom control and regulation of the menstrual cycle with long term care. After an initial program of care, many of my clients have gone on to manage their PCOS with the diet and lifestyle strategies outlined in this article with minimal need for herbal maintenance.

development of numerous immature cystic follicles. This in turn perpetuates elevated LH (luteinising hormone) and lowered FSH (follicle stimulating hormone) levels. Excess weight gain: an increase in fatty tissue leads to the conversion of androgens to oestrone (aromatisation) which increases the levels of the non-variable oestrogens (it has been suggested that marked weight gain can trigger PCOS in some individuals). Adrenal dysfunction: excessive adrenal production of androgens leads to elevated oestrone. Hypothalamic-pituitary axis dysfunction: inappropriate GnRH (gonadotropin releasing hormone) release leads to elevated LH and lowered FSH. Genetic predisposition: it has been shown that PCOS may be inherited. Approximately 40% of the women with a family history of PCOS will have the condition. However not all of these will develop symptoms. Leptin regulation: this is a hormone secreted by the adipocytes that regulate body weight. Researchers have postulated that leptin may have an effect on follicular maturation and the development of obesity. Its full role in PCOS is yet to be ascertained.

Possible Causes of PCOS

The exact aetiology of PCOS remains unclear and controversial. Traditional thought focussed on genetic predisposition, ovarian dysfunction and the resulting excess androgens. However new research centres on the roles of insulin resistance, impaired glucose tolerance and leptin. Possible causes are summarised as follows. Insulin resistance: through complex metabolic pathways, elevated insulin levels lead to increased ovarian androgens, increased adrenal androgens, increased triglycerides and decreased HDLcholesterol. Ovarian dysfunction: very low oestradiol and very high ovarian androgens lead to elevated acyclic oestrogen (oestrone) which potentiate the
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PCOS Symptom Picture

Of those women diagnosed with PCOS: 90% will suffer from secondary amenorrhoea or oligomenorrhoea 90% will suffer from hyperinsulinaemia (in both non-obese and obese women) 6585% will show multiple ovarian follicles on ultrasound 75% will suffer from infertility (including recurrent miscarriages) 5060% will suffer from hirsutism and/or accelerated scalp hair fall 50% will not menstruate 40% will be significantly overweight 40% will suffer from adult acne 30% will suffer from abnormal bleeding patterns
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25% will suffer from latent or frank hyperprolactinaemia 15% will be experiencing ovular cycles if they are menstruating a very small percentage will suffer from masculinisation (deeper voice and change in body structure)

cyproterone acetate (antiandrogenic): to treat acne and hirsutism oral contraceptive pill (especially those containing cyproterone acetate) to treat acne and hirsutism spironolactone (diuretic, aldosterone antagonist): to treat acne and hirsutism progesterone, oral and micronised: to trigger withdrawal bleeding clomiphene (oestrogen agonist or antagonist (depending on the target tissue)): to improve ovulation and fertility for those wishing to conceive

PCOS Diagnosis
Diagnosis of PCOS can be complicated by the fact that several other endocrine neoplasms and disorders have a similar symptom picture. Therefore a thorough diagnostic workup is warranted to rule out other diseases. Initial investigations should include serum FSH, LH, FAI (free androgen index), SHBG (sex hormone-binding globulin), DHEA (dehydroepiandrosterone sulfate), free testosterone, and fasting insulin levels. This can be followed by, as appropriate, thyroid function test, blood lipid evaluation, prolactin levels and an oral glucose tolerance test depending on the patients symptom picture and initial test results. Exact diagnostic criteria remain contentious. Once other disorders have been ruled out, diagnosis is made if a woman has several of the following signs or symptoms: irregular ovulation hirsutism elevated FAI polycystic or pearl necklace ovaries present on ultrasound hyperinsulinaemia: fasting insulin levels of 1014 IU/L are indicative, > 20 IU/L are diagnostic Other signs strongly indicative of PCOS include: elevated testosterone acyclical hyperoestrogenism: usually oestrone rather than oestradiol elevated 17-hydroxyprogesterone elevated LH with relatively low or constant FSH i.e. a LH:FSH ratio > 2 lowered SHBG

A 2003 meta-analysis noted that metformin is an effective treatment for anovulation in women with PCOS. Metformin had a significant effect in reducing fasting insulin levels, blood pressure and low-density lipoprotein cholesterol. There was no evidence of an effect on body mass index (BMI) or waist:hip ratio. The authors recommended that metformin should not be proposed as a replacement for increased exercise and improved diet. Metformin was associated with side effects of nausea, vomiting and other gastrointestinal disturbances.2 Surgical ovarian wedge resection was the first established treatment for anovulatory PCOS patients, but was largely abandoned because of the risk of postsurgical adhesion formation. A newer surgical therapy, laparoscopic ovarian drilling, is done with less trauma and fewer postoperative adhesions.3 A 1998 review of laparoscopic surgical techniques for ovulation induction in PCOS patients found that adhesions were less frequent after laparoscopic multiple biopsies, but they were observed in about 90% of patients after resection by laparotomy, in 30% of patients after laparoscopic electrocauterisation, and in 50% after laparoscopic laser vaporisation.4

Treatment Principles of PCOS

Treat insulin resistance and normalise blood sugar economy. Normalise weight: BMI < 25, waist:hip ratio < 1. Re-establish regular menstruation. Normalise ovulation and reduce androgens. Reduce long-term cardiovascular disease and noninsulin-dependent diabetes risk.

Treatment of PCOS
Orthodox Treatment
Medical drug therapy metformin (hypoglycaemic): to moderate insulin resistance

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Herbal Treatment of PCOS

Initiate ovulation, normalise follicle development, tonify the reproductive system and improve fertility Paeonia (Paeonia lactiflora), Tribulus (Tribulus terrestris), wild yam (Dioscorea villosa), shatavari (Asparagus racemosus), true unicorn root (Aletris farinosa), dong quai (Angelica sinensis), Rehmannia (Rehmannia glutinosa), and black cohosh (Cimicifuga racemosa), (false unicorn root (Chamaelirium luteum) is no longer recommended here due to its threatened status) Decrease androgens Paeonia and licorice (Glycyrrhiza glabra) (high in glycyrrhizin), and if needed add soya Decrease LH black cohosh, hops (Humulus lupulus), bugleweed (Lycopus virginicus), Paeonia and licorice Treat latent hyperprolactinaemia chaste tree (Vitex agnus-castus) and Paeonia (via dopamine modulation) Support luteal phase of the menstrual cycle chaste tree Reduce insulin resistance Gymnema (Gymnema sylvestre), goats rue (Galega officinalis), fenugreek (Trigonella foenum-graecum), bitter herbs, Korean ginseng (Panax ginseng), Siberian ginseng (Eleutherococcus senticosus) and sarsaparilla (Smilax ornata) Support liver function phase I: St Marys thistle (Silybum marianum); phase II: Schisandra (Schisandra chinensis), turmeric (Curcuma longa) and rosemary (Rosmarinus officinalis); other: Bupleurum (Bupleurum falcatum) (especially for long menstrual cycles) Reduce cardiovascular risk soya isoflavones and Korean ginseng Support adrenal function licorice, Rehmannia and Withania (Withania somnifera) Soften scarring if needed Calendula (Calendula officinalis), gotu kola (Centella asiatica) and possibly dan shen (Salvia miltiorrhiza) Treat cysts Thuja (Thuja occidentalis), poke root (Phytolacca decandra), red clover (Trifolium pratense) and violet leaves (Viola odorata) Improve hirsutism licorice, Paeonia; possibly damiana (Turner diffusa), saw palmetto (Serenoa serrulata) and sarsaparilla

Some authors do not agree that using chaste tree in PCOS is useful and recommend against it as they have observed in clinical practice that it worsens menstrual irregularity in some cases. As a result they feel that more research is required for using chaste tree in PCOS.5 However, other practitioners use it routinely in this disorder, especially to promote fertility.

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Clinical Studies
A combination of licorice and Paeonia was found to be beneficial for normalising serum testosterone and producing regular ovulation in women with PCOS. Some women became pregnant after treatment. The effect was somewhat dependent upon the type of PCOS experienced. The administered dosage was equivalent to 48 g/day of dried herb of each of licorice and Paeonia.6 Gymnema extract has been shown to improve the serum parameters of diabetics. A hypoglycaemic effect has also been suggested for goats rue from early clinical research. (Goats rue contains the active constituent galegine (which is a guanidine derivative) and chromium salts (3.7 ppm).6,7 The drug metformin is a biguanide drug.) Fenugreek seed has been evaluated in a number of clinical trials, the results showing hypoglycaemic and hypocholesterolaemic activity.6

track serum potassium levels). Licorice should not be prescribed when patients are taking the diuretic spironolactone.

CASE STUDIES
The following principles of preconception care (PCC) are advised for at least 4 months prior to conception for both partners: Diet and lifestyle: combination of zone and detoxification protocol, avoiding ALL refined foods, trans fats, sugar, artificial sweeteners, tea, coffee, alcohol, cigarettes, recreational drugs, and any foods or chemicals which trigger sensitivities or allergies. Regular exercise (34 times per week, 2045 minutes) and stress management integrated into daily routine. Nutritional supplementation (PCC protocol): a daily program covering all vitamins, minerals, trace elements, antioxidants, essential fatty acids and probiotics needed for reproductive health, spermatogenesis and oogenesis. For full details see Better Babies by Francesca Naish. Environmental health: a review of exposures to occupational and household toxins i.e. electromagnetic radiation (e.g. mobile phones, personal computers), petrochemicals (i.e. cleaning and gardening products), heavy metals with a focus on avoiding exposure wherever possible and reducing risk where exposure is inevitable. Comprehensive pathology tests and physical exam to check all major organ systems and rule out hormonal imbalance and genitourinary tract infections. HTMA (hair tissue mineral analysis) is recommended to test for heavy metal toxicity and further assess metabolic function. For the female partner: immediate cessation of OCP (oral contraceptive pill) and use of both symptothermal charting and barrier methods for contraception. The natural fertility management (NFM) method of symptothermal (ST) charting tracks cervical mucus, basal temperature and lunar fertility along with the secondary signs and symptoms indicative of PMS (premenstrual syndrome) and hormonal imbalance. For more information refer to Natural Fertility by Francesca Naish.

PCOS: Naturopathic Care

Treat insulin resistance: initially a supervised weight loss program utilising a ketogenic or zone diet protocol may be needed followed by maintenance on a small meals frequently low glycaemic index/zone diet protocol. Consistent aerobic and anaerobic exercise is essential. Enhance oestrogen balance and clearance: ensure an intake of dietary fibre of 40 g/day, encourage abundant vegetables and leafy greens from the Brassica family and bitter greens, encourage dandelion tea/coffee, include cultured dairy products, reduce saturated fats, ensure adequate protein (lean meats, legumes, tofu and tempeh) and include dietary phyto-oestrogens especially linseed. Minimise exposure to xeno-oestrogens wherever possible: encourage the use of organic and biodynamic food especially dairy, poultry and meat products, avoid plastic food containers and wraps, decrease (and if possible avoid) use of petrochemical-based toiletries, cosmetics and household cleaning products. Avoid all social poisons: coffee, alcohol, all refined sugar and associated products, trans-saturated fats, cigarettes and excess refined salt. Key nutrients: chromium, coenzyme Q10, lipotrophic nutrients, magnesium, omega 3 fatty acids, silica, soya isoflavones, vitamin B complex with good levels of vitamin B6, vitamin E, zinc. Licorice considerations: when administering licorice long term it is necessary to closely monitor blood pressure, ensure that the diet is high in potassium and low in sodium (you may need to

The above information was recommended in the cases which follow and is not repeated below.
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Case Study 1
Detoxification & Stabilisation (OctDec 2001)
31-year-old Chloe had been trying to fall pregnant for 4 years when she sought my help. For the last 3 years she and her husband Jack had been working with IVF treatment every 2 months to no avail. They were investigating the possibility of adoption but also wanted to work with NFM. Chloe began using the OCP during her early twenties. When she came off the pill in 1998 she failed to recommence her menstrual cycle and was diagnosed with PCOS. Her menstrual pattern since menarche at 13 years was an irregular 3049 day cycle with a moderate, clotty 35 day bleed. She had moderate dysmenorrhoea for the first 23 days of her cycle, suffered from breast tenderness, anxiety, irritability, sugar cravings, abdominal bloating and acne for 37 days premenstrually. Since stopping IVF treatment in July 2001 she had menstruated twice, with cycles of 45 and 47 days. Chloe was very fatigued with a wide range of symptoms indicative of insulin resistance, dysbiosis and poor liver function. Her diet was generally adequate in terms of nutrients, but was too high in refined carbohydrates, refined foods generally and caffeine. Her exercise pattern was sporadic at best.

(Chelidonium majus) and fringe tree (Chionanthus virginicus): 2 tablets b.i.d. and tablets containing Schisandra, St Marys thistle and rosemary (Rosmarinus officinalis): 1 tablet b.i.d. These tablets were used synergistically to support liver function with a focus on supporting phase I and II detoxification, bile production and protecting liver cells during the detoxification process. A broad-spectrum probiotic powder and a gastrointestinal repair powder (both: 1 teaspoon twice daily).

Treatment Rationale
Licorice: adrenal restorative, combined with Paeonia to support the reestablishment of ovulation. Gymnema: tonic for the pancreas and to assist blood sugar economy. Golden seal: mucous membrane restorative (to support fertile cervical mucus production), ovarian tonic. Paeonia: female reproductive tonic, oestrogenic support.

Treatment Regime
Chloe wanted to take a break from the intensity of trying to conceive and agreed to work on her whole body health for several months. During this time we focussed on the gastrointestinal tract, her diet, exercise and lifestyle habits. We began working with her endocrine system and she started tracking her menstrual cycle with ST charting.

The herbal formula and herbal tablets were prescribed at this dosage for 3 months. Her GIT and liver integrity improved markedly with scores on her health appraisal questionnaire (HAQ) dropping from the very urgent category to low priority category. By the end of this time she was no longer suffering from symptoms of malabsorption and dysbiosis. Her blood sugar economy

Herbal Formula
Licorice high grade (Glycyrrhiza glabra) Gymnema (Gymnema sylvestre) Golden seal (Hydrastis canadensis) Paeonia (Paeonia lactiflora) 1:1 90 mL 1:1 180 mL 1:3 90 mL

1:2 180 mL 540 mL

Dose: 6 mL b.i.d. Additionally: Tablets containing St Marys thistle, globe artichoke (Cynara scolymus), dandelion root (Taraxacum officinale), greater celandine

GYMNEMA Modern Phytotherapist 17

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Clinical

stabilised markedly. Chloe worked hard at her diet and exercise program and she lost 3 kg in weight and her BMI improved. Her menstrual cycle began to stabilise immediately to cycles of 35, 32 and 31 days respectively. Her ST charts showed increasing levels of mid-cycle fertile mucus and her temperature readings confirmed ovulation in both November and December. Her PMS symptoms improved across the board by around 70%,

but her skin remained problematic with acne flare-ups premenstrually.

Preconception Care (JanApr 2002)

In the New Year we began the preconception program in earnest. They completed all their fertility pathology tests and HTMA. All their results came back within normal limits.

Herbal Formula
Jan Shatavari (Asparagus racemosus) Licorice high grade (Glycyrrhiza glabra) Gymnema (Gymnema sylvestre) Golden seal (Hydrastis canadensis) Cramp bark (Viburnum opulus) Paeonia (Paeonia lactiflora) 1:2 1:1 1:1 1:3 1:2 1:2 150 mL 70 mL 70 mL 50 mL 50 mL 150 mL 540 mL Dose 7.5 mL b.i.d. Feb 170 mL 75 mL 75 mL 50 mL 170 mL 540 mL 7 mL b.i.d. Mar 170 mL 75 mL 75 mL 50 mL 170 mL 540 mL 7 mL b.i.d. Apr 175 mL 90 mL 90 mL 185 mL 540 mL 6 mL b.i.d.

Herbal Tablets
Jan Tablets containing St Marys thistle, globe artichoke, dandelion root, greater celandine and fringe tree Tablets containing clivers (Galium aparine), sarsaparilla, Oregon grape (Berberis aquifolium), burdock (Arctium lappa) and yellow dock (Rumex crispus) 2 b.i.d. Feb 2 b.i.d. Mar 2 b.i.d. Apr 2 b.i.d.

1 b.i.d.

1 b.i.d.

1 b.i.d.

Additionally: A comprehensive program of multivitamin and minerals, antioxidants and essential fatty acids designed specifically for preconception care.

Chloe worked really well with her diet and lifestyle but struggled to take her herbal formula every day as prescribed (because of the taste). We tried many different strategies to improve her compliance but she only took her herbs about 60% of the time. Despite

this, her menstrual cycle remained stable with ovulatory cycles of between 27 to 30 days. Menstrual cramping was reduced in severity and duration, but still required treatment hence the addition of cramp bark into her formula. Her ST charts showed ovulation between days 13 and 15 each month with small yet adequate levels of mid-cycle mucus so I added shatavari and took out golden seal in an effort to improve this. Over this period of time her PMS and dysmenorrhoea completely resolved. Her acne slowly improved.

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Consolidation & Completion (MayJul 2002)

Herbal Formula
May Gymnema (Gymnema sylvestre) Paeonia (Paeonia lactiflora) Bupleurum (Bupleurum falcatum) Withania (Withania somnifera) Aniseed (Pimpinella anisum) 1:1 1:2 1:2 1:2 1:2 125 mL 125 mL 85 mL 165 mL 40 mL 540 mL Dose 8 mL b.i.d. Jun 125 mL 125 mL 85 mL 165 mL 40 mL 540 mL 8 mL b.i.d. Jul 125 mL 125 mL 125 mL 165 mL 40 mL 580 mL 8 mL b.i.d.

Additionally: For a throat infection: tablets containing Echinacea angustifolia root and E. purpurea root (1 tablet t.i.d.) and tablets containing Andrographis (Andrographis paniculata), Echinacea angustifolia root and holy basil (Ocimum tenuiflorum) (2 tablets t.i.d.). These herbs are specifically indicated for an acute infection. Vitamins and minerals including B vitamin complex, magnesium powder and vitamin ACE and bioflavonoid powder.

months for maintenance and preventative care. Her menstrual cycle remained stable at 2729 days and ovular. She used the NFM method for contraception. Jack and Chloes adopted baby arrived in July 2003 and they have begun preconception care for their next baby.

Case Study 2
Initial Consultation Nov 2002
30-year-old Louise presented with amenorrhoea since ceasing the OCP in July 2002. She was feeling generally unwell, extremely fatigued with poor stamina and endurance despite daily exercise, appropriate diet and adequate sleep. She felt as if she was suffering from PMS constantly. She had taken the OCP from age 1829 with a 6-month break at 24 years. She had always experienced mild to moderate side effects on the pill: PMS, acne, weight gain and monthly vaginal thrush. However from December 2001 to June 2002 she felt that these symptoms markedly worsened in frequency and severity prompting her to cease taking the OCP. Her HAQ revealed scores in the urgent category for liver and gallbladder, thyroid, ovaries and nervous system (anxiety, depression) and in the high priority for gastric hypoacidity, hypoadrenal, hyperglycaemia and hypoglycaemia, PMS, skin and vitality. She had been involved in a serious motor vehicle accident in April 2001 experiencing severe whiplash, lacerations, bruising and soft tissue injuries throughout her thoracic spine and ribcage. She had slowly recovered physically, however her doctor prescribed sertraline from June to March 2002 for post-traumatic stress.

I continued with the licorice and Paeonia combination, including Withania as a nervous system and adrenal tonic, Bupleurum to support liver function and aniseed as a carminative (for stress-related indigestion) and flavouring agent. I used licorice long term, and the formula worked so well that I kept her on it. I closely monitored her blood pressure monthly to fortnightly and watched for signs of hypokalaemia. She was also on a low sodium/high potassium diet. Ironically just as Chloe and Jack were ready to begin attempts at conception their life went into a state of organised chaos. Amongst other things, they were accepted into the final stages of application to adopt an overseas baby, and decided to stop their preconception care in June. Chloe continued to chart her cycle, which remained stable in length, she continued ovulating but re-experienced PMS and dysmenorrhoea in her July cycle. She also came down with a viral URTI in late June, which we treated acutely.

Epilogue
Since July 2002 Chloe continued to see me every 23

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Magnesium, chromium and B complex powder.

I recommended that Louise work with a combination of an anticandidiasis and zone diet protocol. She increased her water intake and continued with her exercise program.

Treatment Rationale
Paeonia: oestrogenic balance, combined with licorice (in a ratio of 2:1) to initiate support and stabilise ovulation and as a general reproductive tonic. Licorice: also to support adrenal function. Schisandra: liver tonic with a focus on liver detoxification; ovarian tonic and nervous system support. Gymnema: support for both the pancreas and blood sugar regulation. Ginger: warming circulatory tonic.

PAEONIA

Symptom summary: Post-OCP amenorrhoea with ongoing moderate to severe symptoms of PMS types A, C, D and H Weight gain of over 8 kg in the previous 6 months Nervous system and adrenal depletion Symptoms of generalised gastrointestinal malabsorption and dysbiosis Very poor blood sugar economy Acne

2nd Consultation Dec 2002

Louise reported a general improvement of around 50% in terms of energy levels and fatigue, mood stability, coping and gastrointestinal bloating. She noticed a reduction in cravings for refined carbohydrates and the symptoms of hypoglycaemia. She had continued to suffer from mastalgia premenstrually. Her menstrual cycle had recommenced after 26 days of treatment with low grade pelvic cramping on day 1 and 2 of her cycle with a bright steady flow free of clots or flooding. Her acne had flared up considerably. She had lost approximately 3 kg throughout the month. Her total health profile revealed low ferritin, slightly raised glucose levels, positive serum Candida antibody levels, strongly elevated testosterone, LH and FAI; decreased FSH and SHBG. These results were strongly indicative of PCOS so I referred her via a doctor to see an endocrinologist for diagnosis. All major organ systems were functioning within normal limits.

Herbal Formula
Paeonia (Paeonia lactiflora) Licorice high grade (Glycyrrhiza glabra) Schisandra (Schisandra chinensis) Gymnema (Gymnema sylvestre) Ginger (Zingiber officinale) 1:2 180 mL 1:1 90 mL

1:2 115 mL 1:1 120 mL 1:2 30 mL 535 mL

Herbal Formula
Paeonia (Paeonia lactiflora) Licorice high grade (Glycyrrhiza glabra) Schisandra (Schisandra chinensis) Gymnema (Gymnema sylvestre) Ginkgo (Ginkgo biloba) standardised 1:2 150 mL 1:1 75 mL

Dose: 9 mL b.i.d. Additionally: Chaste tree tablets: 2 tablets (taken in the morning). Chaste tree is used to support and stabilise the luteal phase of the menstrual cycle. Tablets containing Withania and Korean ginseng: 2 b.i.d. This combination forms a potent support tool for both adrenal and nervous system functions.

1:2 120 mL 1:1 150 mL 2:1 50 mL 545 mL

Dose: 9 mL b.i.d.
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Additionally: Chaste tree tablets: 2 tablets (taken in the morning) Herbal iron tonic containing Withania, nettles (Urtica dioica), Codonopsis (Codonopsis pilosula), licorice, vervain (Verbena officinalis), ginger plus vitamins (7.5 mL b.i.d.). Magnesium, chromium and B complex powder.

Tricky R. Women, Hormones and the Menstrual Cycle: Herbal and Medical Solutions from Adolescence to Menopause. Allen and Unwin, NSW, 2003, p 356. Bone K. A Clinical Guide to Blending Liquid Herbs: Herbal Formulations for the Individual Patient, Churchill Livingstone, St. Louis, 2003. Bisset NG (ed). Herbal Drugs and Phytopharmaceuticals: A Handbook for Practice on a Scientific Basis. Medpharm Scientific Publishers, Stuttgart, 1994, pp 220-221.

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In addition to the cited references, the following books and articles were used in the compilation of this article:
Tricky R. Women, Hormones and the Menstrual Cycle: Herbal and Medical Solutions from Adolescence to Menopause. Allen and Unwin, NSW, 2003. Naish F. Notes and Seminar Manuals from the Natural Fertility Management Postgraduate Training. The Jocelyn Centre, Sydney, NSW, 1998-2002. Bone K. Clinical Applications of Ayurvedic and Chinese Herbs. Phytotherapy Press, Warwick, 1996. Mills S, Bone K. Principles and Practice of Phytotherapy: Modern Herbal Medicine. Churchill Livingstone, Edinburgh, 2000. Bone K. MediHerb Professional Monitor 1995; 14: 1-2 Kidson W. Med J Aust 1998; 169(10): 537-540 Pugeat M, Ducluzeau PH. Drugs 1999; 58(Suppl 1): 41-46 Tricky R. Aust J Med Herbalism 1999; 11(2): 54-60 Quinn F.. Medical Observer Sept 1999, pp 47-49.

The herbal iron tonic was prescribed because her ferritin levels were low. Ginkgo replaced ginger because it is a more specific treatment for PMS mastalgia and still covers circulation.

3rd Consultation Jan 2003

Louise happily reported that she had just finished her second bleed. The previous cycle had lasted 26 days. She had suffered from mild bloating and breast tenderness for 4 days in the premenstrum however she felt that it had been less severe. Her mood and energy levels had remained stable through the month (despite the fact that she had decided to separate from her husband and had moved out of her home). She continued to suffer from acne along her jaw line however, she felt that generally her skin was improving. She had lost a further 4 kg and was almost at her target weight and BMI. The endocrinologist diagnosed PCOS. Treatment was a continuation of that prescribed in the previous consultation.

4th, 5th, 6th Consultations FebJul 2003

Louise continues to see me monthly and has been on a very similar program to that outlined above (with the addition of Tribulus terrestris tablets, 1 t.i.d.). During this time she relocated to another town, changed jobs and is in a happy new relationship. She and her partner are now in the first month of their preconception care program and are planning to start their family late in the year. Louises cycle has remained stable and ovular for the last 6 months. Repeat hormone tests showed that her testosterone, SHBG, FAI and LH levels had normalised. The majority of her PMS symptoms are a thing of the past. The only issue remaining is her acne which remains stubbornly resistant to treatment.
REFERENCES
1 2 3 4 Kelly CJ, Gordon D. Eur J Endocrinol 2002; 147(2): 217-221 Lord JM, Flight IH, Norman RJ. Cochrane Database Syst Rev 2003; (3): CD003053 Farquhar C, Vandekerckhove P, Lilford R. Cochrane Database Syst Rev 2001; (4):CD001122 Campo S. Obstet Gynecol Surv 1998; 53(5): 297-308

Samantha Bulloch
BAppSc, ND

Samantha began her work in the health profession by completing the Bachelor of Applied Science (Nursing) at Curtin University, Western Australia in 1988. In the following years she worked in major NSW teaching hospitals specialising in paediatrics. Samantha completed her Naturopathic Diploma at Perth Academy of Natural Therapies, Australia in 1998. Her previous nursing background and experience along with parenting ignited a passion for preventative health and she decided to focus on preconception care and fertility. She has been fully accredited in both the foundational and advanced training in Natural Fertility Management and since 1998 she has worked full time in her practice specialising in male and female reproductive health, infertility and preconception care.

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