Polycystic ovary syndrome (PCOS) is a common gynecologic endocrine disorder, the etiology of which is unclear. Obesity is seen in 50-75% of patients with PCOS and can begin as early as peri-puberty. It is caused by insulin resistance, abnormal glucose tolerance, excess androgens and an increased proportion of unconjugated testosterone, and is also associated with abnormal leptin and long-term stimulation by estrogen. Obesity (especially central obesity), hyperandrogenism and insulin resistance are three causal and mutually reinforcing factors, with insulin resistance seriously affecting the long-term health outcomes of PCOS patients. Adverse lifestyle and environmental factors contribute to the development of PCOS.
Polycystic ovary syndrome does not have an exclusive name for the disease in the ancient books of Chinese medicine. Based on the main clinical manifestations of the disease, it can be classified as amenorrhea, hypomenorrhea, late menstruation and infertility. Prof. Zhaoling You, our mentor, has unique experience in the treatment of polycystic ovary syndrome. With her years of clinical experience, she pointed out that the treatment is based on two types of evidence: fat and thin.
1.Treatment for patients with fertility requirements
(1) Purpose of treatment
To promote ovulation and normal pregnancy in patients with anovulation. Based on the principle of regulating menstruation and seeds, we follow the three steps of regulating menstruation – warming the nest, regulating the bubble – helping pregnancy and nurturing the fetus.
(2) Basic treatment
Because PCOS patients often have hyperandrogenemia and hyperinsulinemia, you often instruct obese patients to reduce 5% or more of their total body weight through a low-calorie diet and energy-consuming exercise, which can change or reduce menstrual disorders, hirsutism, acne and other symptoms and facilitate the treatment of infertility, avoid hairy substances (shrimp, crab, dog meat, leek, carp, carp, lettuce, bamboo shoots, pig’s feet, chicken, pumpkin) for It is also important for PCOS patients. For lean patients, a low-calorie, no-hair diet and aerobic exercise are also recommended, not to lose weight but to improve insulin resistance and thus improve reproductive function.
(3) Chinese medicine treatment
The treatment is divided into three stages: menstrual phase, follicular phase and luteal phase.
The menstrual period is the process of alternation between the old and the new. During this period, the main objective is to regulate the qi and blood, and to facilitate the flow of blood to the uterus, so that the full blood will go down according to the time. The treatment is mainly on the 1st to 6th day of menstruation, locating the liver, heart and spleen, and adding and subtracting from the formula with Prosperity San as the base. The patient is advised to eat iron-rich, laxative foods during menstruation, such as fish, eggs, pork liver, soy products, fresh vegetables, peanuts, honey, etc. Do not consume strong tea and cold, sour and spicy products, such as cold drinks, bitter melon, cucumber, cold vegetables, chili, cinnamon, dog meat, mutton, white wine, vinegar, plums, lemons, plums, hawthorn, etc.; avoid vaginal medication, douching and strenuous exercise.
The principles of follicle regulation during the follicular growth period are: benefit the kidneys and spleen, warm the nest and increase fluid, help nourish the follicular membrane, promote the rapid growth of the follicle, follow the trend, nourish the kidney essence and help the membrane grow. The formula is based on the following principles The formula is based on the following formula: Radix Rehmanniae Praeparata, Radix Rehmanniae Praeparata, Radix Salviae Miltiorrhiza, Radix et Rhizoma Polygonati, Radix et Rhizoma Polygonati, Radix et Rhizoma Polygonati and Radix et Rhizoma Polygonati. It is also combined with Nuan Nao Bo (composed of Astragalus, Bacopa monniera, Dendrobium earl grey, Huang Jing and Yam) to warm the nest and fill the essence, protect the eggs and nourish the follicles to promote follicle growth, development and expulsion. For women who want to conceive, Dr. You asked them to measure their basal body temperature every day and to make it a habit to measure their basal body temperature. You can eat shrimp skin, pigeon meat and eggs, quail meat and soy milk once a day in the middle of menstruation. As some PCOS patients have unruptured follicular luteinization syndrome, the professor combined the characteristics of this disease with various methods of treatment, including moxibustion of the feet, San Yin Jiao and A-Yi points, 1-2 times a day; jumping rope 200 times or climbing stairs for 60 minutes, 1-2 times a day; decoction of 50g of mugwort leaves and 10g of ginger to soak the feet once a day; applying pressure to the ear points of internal genitalia, pelvis, heart and Shen Men twice a day She also created her own rhythmic tapping method to promote follicular discharge.
During the luteal phase, Prof. You focused on dietary therapy and instructed the patient to take the bedtime pot orally. The bedtime pot consists of 10 herbs, including Radix et Rhizoma Ginseng, Radix Astragali, Longan Pulp and Panax Ginseng Flower. After pregnancy, do not go up to heights, lift heavy objects, or apply emergency brakes; when coughing, sneezing, or vomiting, cover the abdomen with both hands; keep bowel movements smooth, avoid constipation and diarrhea; live a regular life, pay attention to nutrition, maintain a relaxed mood, and prevent cold and disease; avoid strenuous exercise and sexual intercourse before 13 weeks of pregnancy, and avoid indiscriminate use and abuse of drugs.
2.Treatment for patients without fertility requirements
(1) Treatment objectives
The immediate goal is to adjust menstrual cycle, treat hirsutism and acne, and control weight; the long-term goal is to prevent diabetes, endometrial cancer, and cardiovascular disease.
(2) Lifestyle modification
Lifestyle modification: Mainly diet control, exercise and lifestyle change, smoking cessation, alcohol cessation, and avoidance of hair products. Through behavioral modifications, weight loss to improve insulin resistance and weight reduction to normal range can stop the long-term development of PCOS with adverse consequences such as diabetes, hypertension, hyperlipidemia and cardiovascular disease and other metabolic syndromes.
(3) Chinese medicine treatment
You Lao pays particular attention to individual differences in medication and develops different treatment plans according to the actual situation of the patient. patients with PCOS tend to have two types of body type concentrated distribution. One is the second sex characteristics performance is not obvious, breast development is not abundant, the body is thin that is thin type, you master think this type of patients disease is mainly in the heart and liver, treatment to dredge the liver and fire to nourish the heart, mainly using anti-androgen Dan Pi, Gardenia, Zhi Mu, Huang Bai and other drugs. Another type of patient is the common obese body type. Master You believes that this type of patient is mainly located in the heart and spleen, so the treatment is based on tonifying the kidney and strengthening the spleen, resolving phlegm and dispelling dampness. Master You often adds adzuki beans, barley, large belly skin, zedoary, and winter melon skin in the formula to treat their obesity, and instructs patients to control their diet and strengthen exercise, often while patients lose weight, clinical symptoms and various laboratory indicators have significantly improved.
3, details of lifestyle conditioning
(1) the impact of poor lifestyle on PCOS
Bad lifestyle includes high-calorie diet, high-fat diet, low physical activity, smoking, alcohol consumption, etc. In terms of PCOS, poor lifestyle mainly promotes the development of metabolic disorders and obesity, damages reproductive health and increases the risk of developing diabetes and cardiovascular disease in the long term.
(1) Obesity and reproductive function
The higher rates of infertility and spontaneous abortion in PCOS patients compared to healthy women are mainly related to high levels of luteinizing hormone, insulin, androgens and fibrinogen activation inhibitor-1. Numerous studies have demonstrated that simple obesity, or even slight overweight (30 > BMI > 25), can also cause reduced fertility. The coexistence of obesity and PCOS worsens the situation, and Lintsen et al. reported that when undergoing in vitro fertilization, obese PCOS patients are less responsive to clomiphene and gonadotropin-releasing hormone, often requiring higher doses of drugs to induce ovulation; they also have low oocyte production, delayed follicular development, low conception rates and high miscarriage rates.
②Obesity and metabolic syndrome
Metabolic syndrome is a pathological state in which a variety of metabolic components are abnormally aggregated, and its diagnostic criteria have not been unified internationally. Most include: abdominal obesity or overweight. Atherosclerosis, hypertriglyceridemia and low HDL levels. Hypertension. Insulin resistance or hypoglycemic tolerance. Some also include microproteinuria, chronic inflammatory response (increased C-reactive protein), and abnormal coagulation (increased fibrinogen activation inhibitor-1). The metabolic syndrome is a strong predictor of risk for diabetes as well as cardiovascular disease, with a prevalence of more than 40% in patients with PCOS, much higher than in control women of similar age. This shows that obesity, especially centripetal obesity, is closely associated with metabolic syndrome, diabetes mellitus and long-term cardiovascular complications.
(2) Lifestyle modification for PCOS
Lifestyle modification, i.e. “diet control + exercise + behavior” correction, has become the primary treatment strategy for obese women with PCOS. In terms of principles, it should be based on exercise and diet modification, with behavior modification as the key technique, and daily life as the basic occasion, with the participation of family members and obese people, to create a relaxed environment and make it persistent.
① Diet therapy
Low-calorie diet
The purpose of diet therapy is to control the total calorie intake of the body by reducing the calories in food in order to reduce weight. According to the amount of daily calorie intake, foreign diet therapy is divided into food reduction therapy that is low energy diet, semi-starvation therapy that is ultra-low energy diet, and even hunger strike and fasting therapy. Domestic obesity diet therapy is generally divided into three types: starvation therapy, ultra-low energy diet therapy and low-calorie diet therapy. Starvation therapy, ultra-low energy diet therapy on the body’s normal metabolic process has a large impact, more adverse reactions, not as a conventional method of weight loss. Low-calorie diet therapy with a daily caloric intake of 3344–5016kj, or a daily caloric intake of 41.8–83.6kJ per kg of ideal body weight, is the more commonly used diet therapy in clinical practice.
High-fiber diet
Food fiber is the sum of lignin, polysaccharides and interstitial components of plant cell walls that cannot be digested and absorbed by the human intestine. It includes soluble fiber, such as pectin, gum, plant polysaccharides, etc., mainly from fruits, seaweed, oats and legumes; insoluble fiber, such as cellulose, hemicellulose, lignin, etc., mainly from cereal products. Soluble dietary fiber can lower plasma cholesterol and postprandial blood glucose levels, and has a hypotensive effect.
High polyunsaturated fatty acid diet
Polyunsaturated fatty acids (PUFA) mainly come from vegetable fats, such as cottonseed oil, peanut oil, rapeseed oil, soybean oil, etc., accounting for 40% – 50% of their total fat. linoleic acid, linolenic acid and arachidonic acid in PUFA are essential fatty acids, and the lack of essential fatty acids can lead to a decrease in fertility. Animal experiments show that a high PUFA diet can improve the sensitivity of peripheral tissues to insulin and reduce insulin secretion; reduce triglyceride and cholesterol levels through gene regulation; and increase the synthesis of high-density lipoprotein.
High protein diet
Reducing carbohydrates in food and replacing them with protein can increase satiety and increase the specific kinetic effect of food on energy consumption to aid in weight loss. Whether a high-protein diet can improve insulin sensitivity is still controversial, but most foreign scholars currently believe that a moderate increase in protein intake in the short term can help improve insulin sensitivity, increase hepatic glycogenolysis and reduce body weight.
Quit smoking and alcohol
Tobacco burning can produce and release a large number of toxic substances, such as nicotine, cyanide, carbon monoxide, lead, cadmium and so on. The longer the smoking age, the greater the impact on female reproductive function, with clinical manifestations of low ovarian function and estrogen levels; a significantly higher incidence of premature rupture of membranes, placental abruption, late pregnancy bleeding, fetal growth restriction, stillbirth, fetal finger (toe) malformation and other diseases after pregnancy.
Alcohol standard cup definition: 1 standard cup contains 12g of alcohol, which is approximately equal to the amount of alcohol contained in l hear of beer or 1 glass of wine. Daily alcohol intake was closely associated with metabolic syndrome: women who drank 2, 3, and 4 standard glasses of alcohol per day had 1.23, 1.43, and 1.60 times the incidence of metabolic syndrome than women who drank 1 standard glass of alcohol per day, respectively. Previous studies have suggested that long-term moderate alcohol consumption is beneficial for cardiovascular health, but Fan et al. cited a negative association between total lifetime alcohol intake and cardiovascular health after excluding other confounding factors, so moderate alcohol consumption is not advocated for the prevention of cardiovascular disease. The American Council on Science and Health recommends less than 2 standard drinks of alcohol per day for pregnant women, but some researchers suggest that drinking more than 20 ml of alcohol per day may result in a significant reduction in fetal head circumference, and that drinking more than 100 ml of alcohol per week before and after conception may cause fetal growth restriction. In conclusion, in order to avoid further deterioration of metabolic syndrome and the adverse effects of alcohol on the fetus, all alcoholic PCOS patients should abstain from alcohol.
②Exercise therapy
Scientific and reasonable exercise can effectively consume fat and sugar in the body, so that the consumption of calories is greater than the intake, thus achieving the effect of weight loss. The literature shows that exercise can lower insulin levels and improve insulin resistance. Animal experiments have shown that exercise can also directly improve the neuroendocrine function of the ovaries. Exercise therapy has been the basic method for weight loss because of its positive effect on weight loss and its ability to enhance physical fitness. 45 min of aerobic exercise can improve insulin resistance through a series of effects such as increasing glycogen synthesis in the liver, upregulating glucose transporter protein expression in skeletal muscle and increasing phosphorylation of insulin receptors. It can be seen that enhancing exercise is an effective measure to improve insulin sensitivity in all insulin resistant individuals.
Moderate, regular and long-term aerobic exercise is the best choice for obese patients to reduce weight. Aerobic exercise is any rhythmic exercise with a long exercise time and a moderate or small degree of exercise intensity. It must have 3 conditions: the energy required for exercise is mainly provided through the oxidation of fat or sugar and other substances in the body; most of the muscles of the whole body (2/3) are involved in exercise; the intensity of exercise is between low and moderate, and the duration is 15 to 40min or longer. The current general recommendations for exercise are: 30 min five times a week, and aerobic exercise involving large muscle groups, such as quadriceps and biceps, is advocated. There are many forms of aerobic exercise, such as brisk walking, jogging, aerobics, swimming, cycling and various treadmill exercises. The intensity of aerobic exercise varies from person to person, and a simple and effective way to calculate the intensity is to monitor the heart rate during exercise, that is, after the end of the exercise measured 10s pulse number multiplied by 110% to derive the heart rate during exercise: 20-30 years old should maintain a heart rate of about 140/min during exercise, 40-50 years old heart rate of 120-135/min, 60 years old and above heart rate of 100- 120 / min for aerobic exercise range.
③Behavior therapy
Behavior therapy is also known as behavior modification therapy. It is under the guidance of psychiatrists and the help and supervision of family members, so that patients gradually and consciously change the psychological state and habits that are easy to cause the disease, and replace them with psychological states and habits that are conducive to disease treatment. The study found that compared with the control group, the psychological pressure of PCOS patients is greater, obese patients because of obesity and more low self-esteem, reluctant to interact with others, reluctant to exercise to avoid exposing themselves to everyone; menstrual disorders, infertility make them low self-esteem, depression, anxiety and even doubt their fertility, some even self-loathing, overeating, reluctant to exercise. Through the guidance of psychiatrists and the help and supervision of family members, patients can gradually and consciously change their psychological states and habits that easily cause diseases.
Patients with obesity and anovulation should be informed that menstrual disorders and anovulatory infertility have an important relationship with obesity, and the indicators of anovulation and metabolic disorders should be analyzed. Inform about the serious consequences if this continues: abnormal lipid metabolism, abnormal glucose tolerance and/or type 2 diabetes, hypertension, etc. (be specific, detailed and describe with examples of common diseases). Explain the importance of weight loss to the patient and his or her family, and ask the family to monitor and cooperate with the weight loss. Make it clear that weight reduction is the best treatment that will not only restore ovulation and promote fertility, but also prevent the development of serious metabolic diseases, that its therapeutic effects are even better than those of drugs, and that long-term adherence will have lifelong benefits. Before developing an individualized weight loss program, it is important to do self-observation and assessment of various life behaviors. The weight loss person keeps a daily weight loss diary and diet diary. Behavioral therapy emphasizes on a comprehensive understanding of the problems of diet and exercise behavior of obese patients, starting from lifestyle interventions to fundamentally motivate obese patients to change the bad habits closely related to the occurrence and development of obesity, in order to prevent and control obesity, achieve the purpose of weight reduction and maintain the weight reduction effect.
Lifestyle adjustment should be used as the basis of pharmacological treatment for obese, overweight PCOS patients to exercise and control diet to achieve weight loss can restore health and fertility, save time and money, and also reduce the incidence of metabolic syndrome.