Polycystic Ovary Syndrome (PCOS) is a common endocrine disorder affecting women of reproductive age. For the integrative psychiatrist, understanding the nuances of PCOS is essential due to its impact on mental health and the opportunity to coordinate comprehensive care.
Reproductive Subtype of PCOS
Characteristics
Irregular or absent menstrual cycles
Hyperandrogenism (elevated male hormones)
Polycystic ovarian morphology
Increased difficulty in conceiving due to anovulation
Why PCOS Occurs in the Reproductive Subtype
Insulin resistance, leading to overproduction of insulin and stimulating the ovaries to produce excessive androgens
Genetic predisposition
Inflammatory factors
Metabolic Subtype of PCOS
Characteristics
Insulin resistance and metabolic syndrome
Increased risk of type 2 diabetes and cardiovascular disease
May lack classic reproductive symptoms of PCOS
Why PCOS Occurs in the Metabolic Subtype
Insulin resistance leading to higher insulin levels and overproduction of androgens
Genetic factors
Obesity, inflammation, and lifestyle
Clues for the Psychiatrist: When to Consider PCOS
Mood Disorders
Women with PCOS are at increased risk of developing mood disorders, including depression and anxiety. A patient’s mood disorder that is difficult to manage or is cyclic may be a clue. Pay attention if there seems to be a significant hormonal association with their mental health symptoms.
Antipsychotic-Induced Weight Gain
Women taking antipsychotic medications who experience significant weight gain and develop insulin resistance may warrant an evaluation for PCOS.
History of Irregular Menstrual Cycles
A history of irregular, infrequent, or prolonged menstrual cycles is a hallmark symptom of PCOS.
Clinical Signs of Hyperandrogenism
Signs of hyperandrogenism in a female patient (e.g., hirsutism, acne, androgenic alopecia) might signal PCOS.
Chronic Pelvic Pain
Chronic pelvic pain or discomfort, especially when associated with menstrual irregularities, might raise a suspicion for PCOS.
Infertility or Difficulty Conceiving
Patients struggling to conceive due to absence of ovulation should be evaluated for PCOS.
Specific Treatments for PCOS: An Integrative Approach
Integrative psychiatrists, with their broad understanding of mental, emotional, and physical health, are well-positioned to offer or recommend treatment strategies that can address the multidimensional aspects of PCOS. Here are some key options:
Nutritional Counseling
Low-Glycemic Diet: Encouraging a diet focused on low-glycemic index foods can help to manage insulin levels and weight. A continuous glucose monitor (CGM) may be a helpful tool that allows for detailed, continuous monitoring of blood glucose levels.
Anti-inflammatory Diet: A diet rich in omega-3 fatty acids, antioxidants, and fiber can help reduce inflammation.
Exercise and Physical Activity
Regular exercise, including both aerobic and strength training activities, can help to improve insulin sensitivity, regulate menstrual cycles, and manage weight.
Stress Reduction Techniques
Mindfulness and Meditation: Encouraging practices like mindfulness, meditation, or yoga can help to reduce the chronic stress that often exacerbates PCOS symptoms.
Biofeedback and Neurofeedback: These techniques can help patients to develop more control over physiological functions that can impact stress.
Herbal and Nutritional Supplements
Inositol: Shown to improve insulin sensitivity and reduce androgen levels, thereby helping with weight management and menstrual regulation.
Omega-3 Fatty Acids: Can help to reduce androgen levels and improve mood symptoms.
Vitamin D: Many women with PCOS are deficient in Vitamin D, and targeted supplementation can improve metabolic and inflammatory markers.
Medication Management
Metformin: Although not a psychiatric medication, metformin can improve insulin resistance and may be a treatment that integrative psychiatrists discuss with patients in coordination with their primary care or specialty providers.
Selective Serotonin Reuptake Inhibitors (SSRIs): These can be effective in managing co-occurring mood disorders in patients with PCOS.
Mind-Body Therapies
Acupuncture: Some evidence suggests that acupuncture can help to regulate menstrual cycles and improve hormonal balance in PCOS.
Cognitive Behavioral Therapy (CBT): Effective for managing stress, depression, and anxiety that can co-occur with PCOS.
Coordination of Care
Collaborate closely with OB/GYN, endocrinologist, or primary care physician for medication management, such as hormonal contraceptives or anti-androgens that can regulate menstrual cycles and reduce hirsutism and acne.
Potential Emerging Treatments: Spotlight on Allopregnanolone
As an integrative psychiatrist, staying abreast of emerging research and potential new treatment options is essential. One such promising avenue of research is focused on the neurosteroid allopregnanolone. In psychiatry, we already have brexanolone as a treatment option, which is a formulation of allopregnanolone. It was approved by the FDA in 2019 for the treatment of postpartum depression. This was a significant step, as it introduced a new class of medications for depression, acting through a different mechanism than traditional antidepressants.
What is Allopregnanolone?
Allopregnanolone is a neuroactive steroid produced in the body as a metabolite of progesterone. It is known for its potent effects on the GABA (gamma-aminobutyric acid) receptors in the brain, which are the primary inhibitory neurotransmitters. Allopregnanolone has anti-anxiety, anti-stress, and possibly anti-depressant effects due to these GABA-modulating properties.
Allopregnanolone and PCOS: The Connection
Women with PCOS often have altered levels of various hormones, including progesterone. Since allopregnanolone is a metabolite of progesterone, this could potentially affect the levels of allopregnanolone in women with PCOS. Some recent research suggests that allopregnanolone could play a role in the neuropsychiatric symptoms often associated with PCOS, such as anxiety and depression.
Potential Treatment Implications
There is growing interest in the potential of allopregnanolone as a treatment for various neuropsychiatric conditions. Some of the key potential benefits for women with PCOS might include:
Mood Regulation: Given its potent effects on GABA receptors, allopregnanolone may help to stabilize mood and reduce anxiety and depressive symptoms that are common in women with PCOS.
Stress Reduction: Allopregnanolone’s potential anti-stress effects could be particularly beneficial for women with PCOS, who often experience chronic stress.
Patient Education and Advocacy
Educate patients about the nature of PCOS and empower them with knowledge to be an active participant in their healthcare journey. Encourage them to discuss concerns with their OBGYN and get an adequate workup.
Advocate for comprehensive care that addresses not just the physical, but also the emotional and mental health challenges associated with PCOS.
For women with PCOS, an integrative and comprehensive treatment approach is often the most effective. Integrative psychiatrists are uniquely positioned to contribute significantly to the care of these patients, addressing both the physical and mental health dimensions of this complex condition. Through a combination of lifestyle interventions, judicious use of medications, and collaboration with other healthcare providers, integrative psychiatrists can play a pivotal role in helping women with PCOS lead healthier and more balanced lives.
This blog post is designed as a general guide. Integrative psychiatrists should use their clinical judgment and consult with relevant specialists as necessary. Always consider patient history, current medications, and contraindications before starting new treatments. This is not a substitute for personalized medical advice, nor is a patient-physician relationship established in this blog post.
If you are interested in an integrative psychiatry approach, you can learn more about our clinic, Driftless Integrative Psychiatry, and become a patient here.
References
General Overview of PCOS
Azziz R, Carmina E, Dewailly D, et al. The Androgen Excess and PCOS Society criteria for the polycystic ovary syndrome: the complete task force report. Fertil Steril. 2009;91(2):456-88.
Reproductive and Metabolic Subtypes of PCOS
Lim SS, Davies MJ, Norman RJ, Moran LJ. Overweight, obesity and central obesity in women with polycystic ovary syndrome: a systematic review and meta-analysis. Hum Reprod Update. 2012;18(6):618-37.
Mental Health in PCOS
Barry JA, Kuczmierczyk AR, Hardiman PJ. Anxiety and depression in polycystic ovary syndrome: a systematic review and meta-analysis. Hum Reprod. 2011;26(9):2442-51.
Inflammation in PCOS
González F. Inflammation in Polycystic Ovary Syndrome: Underpinning of insulin resistance and ovarian dysfunction. Steroids. 2012;77(4):300-5.
Kelley ST, Skarra DV, Rivera AJ, Thackray VG. The Gut Microbiome Is Altered in a Letrozole-Induced Mouse Model of Polycystic Ovary Syndrome. PLoS ONE. 2016;11(1):e0146509.
Escobar-Morreale HF. Polycystic ovary syndrome: definition, aetiology, diagnosis and treatment. Nat Rev Endocrinol. 2018;14(5):270-284.
Inflammation and PCOS Treatment
Tang T, Lord JM, Norman RJ, Yasmin E, Balen AH. Insulin-sensitising drugs (metformin, rosiglitazone, pioglitazone, D-chiro-inositol) for women with polycystic ovary syndrome, oligo amenorrhoea and subfertility. Cochrane Database Syst Rev. 2012;(5):CD003053.
Oner G, Muderris II. Clinical, endocrine and metabolic effects of metformin added to ethinyl estradiol-cyproterone acetate in non-obese women with polycystic ovarian syndrome: a randomized controlled study. Hum Reprod. 2001;16(6): 1360-1364.
Diagnosis and Inflammatory Markers in PCOS
González F, Rote NS, Minium J, Kirwan JP. Reactive oxygen species-induced oxidative stress in the development of insulin resistance and hyperandrogenism in polycystic ovary syndrome. J Clin Endocrinol Metab. 2006;91(1):336-40.
Duleba AJ, Dokras A. Is PCOS an inflammatory process? Fertil Steril. 2012;97(1):7-12.
Treatment Options for PCOS
Legro RS, Arslanian SA, Ehrmann DA, et al. Diagnosis and treatment of polycystic ovary syndrome: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2013;98(12):4565-92.
Nutrition and Lifestyle Interventions
Phelan N, O’Connor A, Kyaw Tun T, et al. Hormonal and metabolic effects of polyunsaturated fatty acids in young women with polycystic ovary syndrome: results from a cross-sectional analysis and a randomized, placebo-controlled, crossover trial. Am J Clin Nutr. 2011;93(3):652-62.
Vitamin D Deficiency in PCOS
Wehr E, Pilz S, Schweighofer N, et al. Association of hypovitaminosis D with metabolic disturbances in polycystic ovary syndrome. Eur J Endocrinol. 2009;161(4):575-82.
Use of Continuous Glucose Monitoring (CGM) in PCOS
Skjaerven KH, Misund A, Sagen JV, et al. Continuous glucose monitoring reveals abnormal features of interstitial glucose excursions in women with polycystic ovary syndrome. Clin Endocrinol (Oxf). 2015;82(4):552-60.
Allopregnanolone, Psychiatry, and PCOS
Schüle C, Nothdurfter C, Rupprecht R. The role of allopregnanolone in depression and anxiety. Prog Neurobiol. 2014;113:79-87.
Meltzer-Brody S, Colquhoun H, Riesenberg R, et al. Brexanolone injection in post-partum depression: two multicentre, double-blind, randomised, placebo-controlled, phase 3 trials. Lancet. 2018;392(10152):1058-1070.