A case study by Marion Mackonochie
Introduction
This was one of my first hormonal cases and it was a great learning experience, as it was clear that the patient’s willingness to make positive changes to diet and lifestyle were key alongside the herbs. I will now often tell patients that the act of taking their tincture is a little regular reminder that they are taking care of themselves because it is important and they are worth it.
Poly-cystic ovarian syndrome (PCOS) is a hormonal imbalance in which androgen levels are chronically high and can cause symptoms such as irregular or absent menstruation, hirsutism, acne, infertility and weight gain. It is the most common hormonal disorder in women of reproductive age, affecting around 20% of women, and is strongly associated with metabolic disorders such as obesity, insulin resistance, inflammation and type 2 diabetes. Women with PCOS are much more likely to have heart attacks or heart disease than women who don’t. Weight loss and successful control of blood sugar levels are effective ways to counter the hormonal imbalance, so it is an ideal candidate for treatment with herbs, dietary and lifestyle advice.
Presentation & Case history
Jemima (not her real name and full consent was granted for this case history to be anonymously shared) presented in her mid-20s with feeling bloated and tired all the time, particularly after eating. She wanted to lose some weight, improve energy levels, and was also trying to get pregnant, however her menstrual cycle was irregular. She had a long cycle and occasionally missed periods, but experienced heavy bleeding that lasted 10 days when it occurred, accompanied by pain and tearfulness. Pre-menstrually Jemima suffered from headaches, anger and sensitivity and this occurred even on the months when there was no bleeding. Although she had some hirsuitism (on her chin, nipples and neck) since the age of 20 and a blood test showing high testosterone in her teens (both indicating PCOS), a blood test and ultrasound scan 5 years previously had not indicated any hormonal imbalance or cysts on her ovaries. Whether to diagnose PCOS is complicated, as it is a collection of symptoms and women may not have all of them.
Jemima had been unwell as a baby with lactose intolerance and possible colic, but was healthy as a child. There was a history of type 2 diabetes mellitis in her family and she struggled with sugar cravings. I felt that the sugar cravings were an indication that she had difficulty with maintaining constant blood sugar levels, which was significant, as poor blood sugar control is strongly linked with PCOS. Her diet was reasonably healthy, but she admitted to eating too many sweet foods.
Her digestion was ok when she paid attention to her diet. However, she got lower abdominal pain and constipation when she didn’t.
Investigations
On examination, Jemima had quite dry skin, particularly on her feet, with a thickened and yellowing toenail, indicating some fungal skin infection.
Her pulse was 66bpm, with a fairly low blood pressure of 100/65. She also complained of slightly cold hands and feet and some thread veins in her thighs. Altogether, this suggested a circulatory system struggling to move blood effectively.
Despite a recent cold, she did not have raised lymph nodes.
A blood test by the GP had shown that she was slightly anaemic, despite eating meat; which may have been linked to the heavy bleeding.
She had some patches of vitiligo, which started appearing at age 10, indicating some auto-immunity.
Diagnosis
The working diagnosis that I settled on was a subclinical PCOS-type hormonal imbalance associated with poor blood sugar regulation.
Additional differential diagnoses were:
- Hashimoto’s hypothyroidism
- Irritable bowel syndrome (IBS)
- PMS
- Fibroids
- Pre-diabetes
Approach to treatment
The working diagnosis of PCOS-type hormonal balance was based on her long cycle, with occasional missed periods, hirsuitism and poor blood sugar control. All of which are signs of the high androgen levels seen with PCOS. It has been suggested that metabolic disorders such as insulin resistance play a role in the cause of high androgen levels and PCOS. Regardless of whether hormone levels were outside of normal ranges, the cycle was disrupted enough to be challenging for Jemima and was likely to be impacting on fertility, so I decided to assume that it would be of benefit to gently nudge them. Paeonia and liquorice are a traditional combination used for PCOS. Liquorice is thought to inhibit an enzyme (17β-hydroxysteroid dehydrogenase) that produces testosterone in the ovaries and hair follicles, while Paeonia acts via the aromatase enzyme to convert testosterone into oestradiol and help to reduce androgens. Supporting stable blood sugar levels was also a priority, as sugar cravings and tiredness after eating indicated that these were spiking and dropping. For this reason, I included cinnamon and Gymnema in her prescription.
The dry skin and tiredness, combined with the autoimmune condition vitiligo were signs that the autoimmune hypothyroid condition Hashimoto’s was a possible differential diagnosis. When one autoimmune condition is present, there is an increased likelihood of others. I was unable to confirm whether blood tests from the GP had tested for this, however, I would hope that it had been ruled out. It is possible that the autoimmunity predisposition is linked to early digestive problems when Jemima was a baby. Thyme has been found to support the immune system to prevent it overreacting, as is the case in autoimmunity, so this was a herb that I considered.
Although mild and largely controlled by the patient eating well, the abdominal pain and bloating meant that I included IBS as a potential diagnosis. This is a functional digestive disorder with no observable pathology, but many possible symptoms that can often cause tiredness. Fortunately, herbs that are helpful for blood sugar control and circulation, such as cinnamon and ginger, are also good digestive herbs that can help here.
First prescription
| Rx1) Tincture | Strength | Quantity |
|---|---|---|
| Glycyrrhiza glabra | 1:3 | 20ml |
| Paeonia officinalis | 1:3 | 20ml |
| Cinnamomum zeylanicum | 1:3 | 10ml |
| Thymus vulgaris | 1:4 | 20ml |
| Gymnema sylvestris | 1:3 | 20ml |
| Arctium lappa | 1:3 | 10ml |
| Zingiber officinalis | 1:3 | 5ml |
| Total | 105 x 2 |
Take 5ml with a little water x3/day
Rx2) Vitex agnus-castus 1:2 30ml
Take 10 drops with water at night
Rx3) Flaxseed oil caps
I didn’t record at the time whether the tinctures were all organic or not, but have a policy of buying organic when available from the supplier I am making a purchase from.
Treatment plan
I encouraged Jemima to consider ensuring enough fibre and fruit and vegetables in her diet to support gut health, as I felt that the possible autoimmunity aspect of her health problems would benefit from improved digestion. Increased fibre is also likely to be helpful to maintain more regular blood sugar levels and slow down glucose absorption in the gut. I also advised her to increase the amount of exercise she was doing and that smoking was likely to make the hormonal imbalance worse.
Other medications and treatments
The flaxseed oil was intended to help with dryness and to provide additional omega-3 fatty acids to reduce any systemic inflammation, which can be a problem in PCOS. Essential fatty acids are also helpful to support a healthy metabolism, which again links in with PCOS.
Follow-up appointments
- At the first follow-up 2 weeks later Jemima was feeling more energised. She had been going to bed early and waking refreshed. Her period 10 days previously had been light, pain-free and short. Pre-menstrually she had been ‘cranky, angry and sad’, but had not had any physical symptoms. She was still feeling a bit bloated and was trying to drink more water.
- At the second follow-up 5 weeks after the last one, her digestion was much better and she had been drinking more water and smoothies with spinach every morning. Her energy was still not great, but she admitted to eating junk food on the weekend. She was still feeling very tired after eating. She had been having early nights and feeling refreshed on waking. Her period had been late, then very short and heavy. She had noted tender breasts and some mood swings.
- At the next follow-up, 1 month after the previous one, her energy levels had been good, with no tiredness. Her period had been due a week before and she was feeling sick. She had done a negative pregnancy test, but was feeling anxious and a bit shakey due to some stressful events in her life. I advised her to stop taking the tincture until she had done another negative pregnancy test. This second test was also negative, so she continued with the tincture, but decided that she was going to stop the herbs after that bottle was finished as her energy and digestion were so much improved.
Follow-up prescriptions – with rationale for changes
The first follow-up prescription was the same as the initial mix apart from replacing 10ml of Arctium lappa (burdock) for 10ml of Foeniculum vulgare (fennel) to help with bloating.
A the second follow-up appointment, energy was a key problem.
| Tincture | Strength | Quantity |
|---|---|---|
| Glycyrrhiza glabra | 1:3 | 20ml |
| Paeonia lactiflora | 1:3 | 20ml |
| Cinnamomum zeylanicum | 1:3 | 15ml |
| Thymus vulgaris | 1:4 | 20ml |
| Foeniculum vulgare | 1:3 | 15ml |
| Schisandra chinensis | 1:2 | 15ml |
The schisandra was added to support her energy levels. It is also a good liver tonic, to ensure that the liver was still being supported despite the lack of burdock.
At the third follow-up appointment, anxiety was an issue.
| Tincture | Strength | Quantity |
|---|---|---|
| Glycyrrhiza glabra | 1:3 | 20ml |
| Paeonia lactiflora | 1:3 | 20ml |
| Cinnamomum zeylanicum | 1:3 | 15ml |
| Vita agnus-castus | 1:2 | 10ml |
| Foeniculum vulgare | 1:3 | 15ml |
| Verbena officinialis | 1:3 | 15ml |
She was regularly forgetting to take vitex drops separately, so I added them into the main mix. The vervain was added for her anxiety, which I felt was contributing to the nausea and shakiness.
Final outcome
The treatment lasted for just over 3 months. A month after Jemima stopped taking the herbs, she was pregnant and is now happily a mother of two.
In this case, I think that it was a combination of the herbs and a few small lifestyle changes that helped to improve blood sugar control and the associated sugar cravings and have a knock-on effect on the PCOS-type hormonal imbalance. The Vitex agnus-castus helped to ensure that ovulation was happening each month and hopefully helped with some of the PMS symptoms, while the liquorice and Paeonia helped to reduce the raised androgens.
For Jemima, it was helpful to add in healthy dietary changes, such as vegetable smoothies, essential fatty acids, more water and fibre, rather than focusing on trying to cut out the sweet treats as a first step. Reduction of the unhealthy foods is much easier psychologically when healthy, filling foods are added in first to reduce the blood sugar lows that trigger a need for sugar. Allowing her to make the connection between the cyclical poor dietary choices, sugar crashes, tiredness, craving for sweet foods and then poor sleep was a turning point. She didn’t need much explanation beyond me just asking about symptoms and then in turn about what her diet had been like recently. The ginger, cinnamon and liquorice are great digestive herbs and likely to have prebiotic effects – feeding the good bacteria in the gut to maintain a healthy microbiome and improve both gut and overall health. On reflection, I should have included fennel from the first prescription, as bloating was one of the key presenting complaints, but it is a fine balancing act trying to decide where to focus first.
Although Jemima had wanted to get pregnant and was being bothered by the irregularity of her periods, once she was feeling more energised, less bloated and better in herself she was happy to stop the treatment.