Polycystic ovarian syndrome (PCOS) — a hormonal endocrine disorder that affects more than 5 million women in the United States alone — manifests itself through a spectrum of symptoms, including irregular or absent menstruation (known as amenorrhea), lack of ovulation, multiple cysts on the ovaries, acne, excessive facial hair (hirsutism), and obesity.1 (Many women with PCOS are of normal weight — referred to as “lean” PCOS.) PCOS is one of the leading reasons behind female infertility, and it also increases the likelihood of miscarriage and infant death during or shortly after birth. Additionally, PCOS can lead to serious health issues, including endometrial cancer, osteoporosis, heart disease, and diabetes.1
While the cause of PCOS is uncertain, complex, and variable, several conditions are present within the bodies of women with PCOS that lead to their often-distressing symptoms. These typically include higher-than-normal levels of male hormones — particularly testosterone — lower-than-normal levels of the female hormone progesterone, elevated levels of the hormone prolactin in some cases, and abnormal insulin regulation.1
Drugs prescribed for PCOS include oral contraceptives, which decrease male hormone levels and may normalize a woman’s menstrual cycle, and metformin (brand name Glucophage®), a drug commonly used to treat type 2 diabetes that has been found to help PCOS patients regulate insulin levels and support conception.1 Women with PCOS who are trying to conceive are sometimes prescribed clomiphene (Clomid,™ Serophene®), a fertility drug that stimulates ovulation.
These pharmaceuticals, unfortunately, are not without significant drawbacks. Oral contraceptive pills often produce myriad side effects (increased appetite, mood swings, weight gain, nausea, etc.), cannot be used by women with PCOS who are trying to conceive, and frequently worsen insulin resistance in PCOS patients.2 Clomid can lead to undesired multiple-birth pregnancies,2 and the US Food and Drug Administration (FDA) warns that it increases the risk of major birth defects and should not be used in pregnancy.3 Although metformin is showing potential to help manage PCOS symptoms and perhaps boost conception chances, some women experience discouraging gastrointestinal side effects from the drug,4 which has not been approved by FDA to treat PCOS.1
“Herbs are important as there are few truly effective pharmaceutical options,” said Jillian Stansbury, ND, a Washington state-based naturopathic physician and author of The PCOS Health and Nutrition Guide (Robert Rose, 2012). “Herbs are a safe and nutritive option to support ovarian function, endocrine feedback loops, thyroid function, and blood sugar regulation and metabolism. I have had a great many patients with PCOS over the years, and can report overall good success in treating the various forms and presentations of PCOS: helping women lose weight, restoring normal menses, helping infertile women to conceive and carry the pregnancy, and improve metabolic function and prevent diabetes” (email, February 11, 2013).
Integrative medicine physician, herbalist, and midwife Aviva Romm, MD, agrees that herbs play a significant role in PCOS treatment. “Weight loss is the most effective intervention, and metformin is actually not a bad option, but of course herbs are natural and generally safe so a great option to at least try for folks wanting to avoid pharmaceuticals,” said Dr. Romm (email, February 10, 2013). “They might be particularly helpful in the insulin resistance aspects of the condition, as well as stress hormone mediation.”
The PCOS section in Dr. Romm’s 2010 book, Botanical Medicine for Women’s Health (Churchill Livingstone), illustrates the potential that herbs offer for this complex condition by presenting a successful case report. Author of the section, Angela Hywood, ND, writes that the PCOS patient took six herbs* — chaste tree berry (Vitex agnus-castus, Lamiaceae), licorice (Glycyrrhiza glabra, Fabaceae), white peony (Paeonia lactiflora, Paeoniaceae), gymnema (Gymnema sylvestre, Apocynaceae), echinacea (Echinacea spp., Asteraceae), and schisandra (Schisandra chinensis, Schisandraceae) — in addition to eating a low-carbohydrate diet. According to the report:
After five months on the herbal protocol, the patient’s cycle regulated to a 32-day length…. Problematic symptoms such as mastalgia [breast pain], acne, and hirsutism diminished significantly during the five-month program. The lipid profile has improved to within normal ranges…. She lost a total of 12 percent body weight in the five months. The client became pregnant in her second month of actively trying to conceive.2
Natural treatment plans formulated for PCOS patients by NDs, herbalists, and integrative physicians typically focus on addressing three main types of PCOS manifestations: (1) hormonal imbalances; (2) insulin, blood sugar, and metabolic sensitivities and/or irregularities; and (3) stress response and management.
“My general approach has emphasized diet and exercise as a foundational therapy,” said Dr. Stansbury, “and I create specific herbal and nutritional protocols for individual patients. Because PCOS has many presentations, there could be a variety of different approaches to address specific presentations.”
The following herbs and other natural approaches for treating PCOS and its symptoms are based on practitioners’ experience in treating women with PCOS, as well as several controlled human studies. The numerous medicinal plants, substances, and techniques discussed herein represent a broad overview of this mixed-source data, and are not being suggested for comprehensive or concurrent use.
Because PCOS is an endocrine disorder, herbs that balance hormone levels can be very helpful in improving most PCOS symptoms, including amenorrhea, infertility, acne, and excessive facial hair. Women who have been diagnosed with PCOS or those who think they might have PCOS should obtain a blood test in order to determine if their testosterone and/or prolactin levels are increased. If they are, Dr. Stansbury suggests chaste tree berry, licorice root, and the Traditional Chinese Medicine (TCM) herb dong quai (Angelica sinensis, Apiaceae) root to restore normal menses. (For herb use during pregnancy, please see the “Conclusion” section on page 63.)
“I have seen many amenorrheic women be able to regain their menses — some of them quite quickly,” said Dr. Stansbury. “I remember one case with a woman who hadn’t had a menses for more than three years begin to menstruate after two weeks on an herbal tincture of chaste tree, saw palmetto, and licorice. And then we did some trial-and-error, and when we stopped the formula, her menses would stop again.”5
Chaste tree has been used for thousands of years for numerous women’s health issues, including menstrual disorders. Although no existing studies have directly examined its effects in PCOS patients, a small collection of published scientific and clinical evidence supports its ability to treat some of the condition’s symptoms.6 Several older clinical trials reportedly found chaste tree to result in normal menstrual cycles,6 and more recent research has shown that it is successful at decreasing elevated prolactin levels and improving fertility and the body’s progesterone-producing process.7
Licorice, a well-researched medicinal plant in the legume family, contains compounds that exhibit estrogenic activity. Some studies have found licorice to reduce testosterone levels in healthy women, suggesting that it might also be useful for women with PCOS.8 Dong quai also exhibits estrogenic activity, and has been used for many years to treat gynecological conditions. While more research is warranted to support its traditional uses, limited evidence has found that it can successfully treat amenorrhea.9
For women whose PCOS-related hormone imbalances are making conception difficult, Dr. Stansbury recommends several herbs, including chaste tree berry, dong quai, Indian kudzu (Pueraria spp., Fabaceae) leaf, and knotweed (Polygonum multiflorum, Polygonaceae) root. Although these herbs have been shown in her clinical practice to help women with PCOS to conceive, Dr. Stansbury notes that success varies and can take longer when working toward this more complex outcome, and thus several herbal combinations are often formulated and tried on each individual patient. In her 1999 book Women’s Encyclopedia of Natural Medicine (Keats Publishing), Tori Hudson, ND, suggests that chaste tree be taken for at least three or four months.6
Additional menstruation-normalizing/hormonal-balancing herbs recommended by various naturopathic doctors and herbalists based on their clinical experience and traditional history include the following:
red raspberry (Rubus idaeus, Rosaceae) leaf
saw palmetto (Serenoa repens, Arecaceae) berry ginger (Zingiber officinale, Zingiberaceae) root/rhizome rosemary (Rosmarinus officinalis, Lamiaceae) herb feverfew (Tanacetum parthenium, Asteraceae) leaf partridge berry (Mitchella repens, Rubiaceae)* mugwort (Artemisia vulgaris, Asteraceae) herb false unicorn (Chamaelirium luteum, Melanthiaceae) root — a North American herb with an at-risk conservation status.
The following phyto-estrogenic herbs also are recommended:
black cohosh (Actaea racemosa, Ranunculaceae) root/rhizome red clover (Trifolium pratense, Fabaceae) flower alfalfa (Medicago sativa, Fabaceae) herb flax (Linum usitatissimum, Linaceae) seed soy (Glycine max, Fabaceae) bean, and hops (Humulus lupulus, Cannabaceae) strobiles.2,5,6,10,11
Although little human clinical research has been conducted on herbs specifically for PCOS treatment, some new studies present promising possibilities. A traditional Japanese formulation of licorice and white peony — called Shakuyaku-Kanzo-To — has been shown in trials on women with and without PCOS to decrease testosterone levels, stimulate ovulation, and promote conception.2
A 2013 Iranian study on dried aerial parts of wood betony (Stachys lavandulifolia, Lamiaceae) found that this mint-family herb ameliorated abnormal uterine bleeding in PCOS patients as well as the synthetic progesterone, and that it lowered testosterone levels and improved ovarian condition more than the progesterone.12
Similarly, a study on the black cohosh root extract Klimadynon® (an ethanolic extract produced by German company Bionorica) found that it increased PCOS patients’ progesterone levels, significantly reduced luteinizing hormone levels, and improved ovulation and endometrial thickness more than Clomid.13 Although pregnancy rates were higher in the black cohosh group, the difference was not statistically significant.
A 2010 controlled trial on 80 women with PCOS found that a maitake mushroom (Grifola frondosa, Polyporaceae) extract significantly increased ovulation when used alone and in combination with clomiphene.14 While subjects taking the maitake had approximately 77 percent ovulation — which Dr. Hudson noted as “quite impressive” — clomiphene rates of ovulation were higher at 93.5 percent.15
Improving Insulin Regulation
Many women with PCOS have insulin resistance, also known as metabolic syndrome, which presents itself through weight gain, high blood pressure, high blood sugar, and high cholesterol. Others experience insulin resistance-related hyperinsulinemia, which is higher-than-normal levels of insulin in the blood that can cause hyperglycemia as well as hypoglycemia (low blood sugar), the latter of which produces symptoms such as lightheadedness, nausea, shaking hands, and confusion. A woman who has been diagnosed with PCOS or who thinks she might have the condition should have her blood tested for insulin sensitivity. If she is found to exhibit full or partial manifestations, the pharmaceutical metformin usually is prescribed, and several herbs and foods exhibit similar therapeutic actions. Due to their inositols and related compounds, Dr. Stansbury noted that legumes are especially good for women with PCOS-related insulin concerns.
“These compounds work together to treat insulin resistance,” she said. “They support signal transduction, the ability of a cell to receive insulin and then tell the nucleus of the cell to respond to it.”
Not only have inositols garnered positive clinical outcomes among herbalists and NDs, but their use in treating PCOS also has been supported by clinical trials. A randomized, controlled clinical trial published in a 2010 issue of the journal Gynecological Endocrinology found that a daily dosage of 4 grams myo-inositol and 400 mcg folic acid significantly increased ovulation and conception rates in infertile PCOS women compared with 1,500 mg daily of metformin.16 Another inositol form — D-chiro-inositol — also has been shown in earlier human studies to be very effective at treating PCOS,17 and more recent research suggests a combination of the two forms may be just as effective.18,19 Studies are currently comparing the two against each other.20 (Furthermore, a small, controlled, randomized clinical trial has shown myo-inositol to be superior to D-chiro-inositol in improving embryo quality and pregnancy rates.21) Good sources of inositols are brown rice (Oryza sativa, Poaceae); legume family (Fabaceae) plants including soy, kidney beans (Phaseolus vulgaris), garbanzo beans (Cicer arietinum), carob (Ceratonia siliqua) — available in powder form or in supplements — astragalus (Astragalus membranaceus), and alfalfa; and legume-family herbs such as licorice. Small amounts of D-chiro-inositol are found in buckwheat (Fagopyrum esculentum, Polygonaceae). Inositol supplements also are available over-the-counter at many health food stores.
Dr. Stansbury recommends eating as much beans as possible. “As much one can stand, thus a cup or more daily,” she said. “Lentils, split pea soup, hummus, baked beans, black bean soup, kidney beans in salads, refried beans.... There are unlimited possibilities.” She additionally recommends prickly pear (Opuntia ficus-indica, Cactaceae) fruit for improving insulin resistance,5 an action that has been supported by years of use in traditional Mexican medicine as well as in preliminary animal and human studies, which found the fruit to lower high blood sugar.22 Additional in vitro and animal studies found prickly pear to lower triglyceride, low-density lipoprotein cholesterol, and total cholesterol levels — all of which can be a concern for women with PCOS. Dr. Stansbury suggests using several tablespoons of prickly pear fruit juice in smoothies or sparkling water, or using a splash with vinegar and oil for salad dressing or as a marinating sauce.5
Vitamin D, which enhances the action of insulin, also can be helpful, as well as the mineral chromium.5 According to the PCOS section in the 2010 book Integrative Women’s Health, “accumulating evidence” supports chromium for enhancement of “the metabolic action of insulin and decreasing total cholesterol and LDL…. It has the greatest benefit on obese, insulin-resistant individuals.”4 Integrative medicine physician and author of this section, Bridget Bongaard, MD, recommends 200 to 1,000 mcg of chromium picolinate per day,4 and the mineral also can be found in brewer’s yeast, hibiscus (Hibiscus sabdariffa, Malvaceae) flowers and calyx, dandelion (Taraxacum officinale, Asteraceae) leaves, stevia (Stevia rebaudiana, Asteraceae), and lemongrass (Cymbopogon citratus, Poaceae).5
Dr. Bongaard additionally advises PCOS patients to consider ingesting moderate amounts of tea (Camellia sinensis, Theaceae) and/or coffee (Coffea arabica, Rubiaceae) due to caffeine’s well-documented ability to improve insulin sensitivity, taking 1 to 6 grams daily of cinnamon (Cinnamomum verum, Lauraceae) for its ability to improve insulin resistance and reduce fasting blood glucose — activities exhibited in human trials — or 200 to 400 mg of alpha-lipoic acid to reduce insulin resistance and oxidative stress.4 Dr. Hywood writes in Botanical Medicine for Women’s Health that the traditional anti-diabetic Indian herb gymnema has been shown in experimental models to lower blood sugar levels by preventing glucose absorption, and that fish oil may also benefit PCOS patients due to its reduction of serum triglycerides.2
Stress Response and Management
An important yet perhaps less-recognized aspect of PCOS treatment is managing a patient’s stress level. As Dr. Hywood explains, “In response to stress, the adrenals release cortisol, inducing an elevation in prolactin … and increased androgen synthesis, which in turn leads to menstrual cycle dysregulation, especially anovulation, characteristic of PCOS.” In fact, Dr. Hywood notes that botanical PCOS treatments should first address stress and that adaptogenic herbs “should be given primary consideration” because they “improve resistance to stress through [modulation] at the adrenal level.” She lists the following herbs as helpful adaptogens for PCOS treatment (plant parts not specified):
ashwagandha (Withania somnifera, Solanaceae) American ginseng (Panax quinquefolium, Araliaceae) and Asian ginseng (P. ginseng) licorice rhaponticum (Rhaponticum carthamoides, Asteraceae) rhodiola (Rhodiola rosea, Crassulaceae) schisandra
In Integrative Women’s Health, Dr. Bongaard recommends various mind-body therapies, including yoga, guided visualization, hypnosis, biofeedback, and aromatherapy for decreasing stress hormones and improving blood pressure and blood sugar. In fact, a recent controlled study conducted in India and published in the July 2012 issue of the International Journal of Yoga found that a daily, hour-long yoga and meditation program improved anxiety symptoms in teenage girls with PCOS.23
Additional supportive therapies for PCOS include nurturing a healthy liver — an organ crucial to the breaking down of excess hormones — particularly through limiting alcohol intake and ingesting liver-supportive herbs such as milk thistle (Silybum marianum, Asteraceae).5 Dr. Stansbury highlighted the significant role that alcohol plays in women with PCOS, for whom she recommends limiting consumption to just a few alcoholic drinks per week, if any at all.
“Alcohol has one of the biggest glycemic indices of any food-stuff, more than eating a spoonful of sugar.5 So if anyone is prone to insulin resistance, quantities of alcohol will just challenge your blood sugar regulation. Alcohol also challenges the liver, of course, and if your liver is busy detoxifying alcohol, then it has less enzymes or less power and reserves to metabolize your hormones.”
Regular and moderate exercise and resultant weight loss is paramount for overweight PCOS patients as it reduces insulin and testosterone levels — often providing dramatic relief of most PCOS symptoms.2,4 “Weight loss alone,” writes Dr. Hywood, “has led to achievement of pregnancy in 60% of cases without other medical intervention.” Likewise, low-carb, whole foods diets also have been shown in clinical experience and human studies to reduce insulin resistance and testosterone levels in women with PCOS.5,24 Additionally, a small controlled clinical trial recently found that acupuncture increased the frequency of ovulation in women with PCOS.25
Although women with PCOS are understandably eager to improve their symptoms, enjoy an improved quality of life, and, often times, to start a family, they must keep in mind that herbal, nutritional, and lifestyle therapies can take time. In fact, Dr. Stansbury recommends that PCOS women hoping to have children “take several months, even a year, to prepare yourself, improve your fertility, and decrease the chance of miscarriage by improving your diet and by taking key supplements.”5
“[Women] might notice improvement as early as a month or two,” said Dr. Stansbury, “but since this is shifting your whole hormonal balance and acting on the liver and adrenals and ovarian function and pituitary feedback loops, I give women a six-month to 12-month game plan.”
If a woman with PCOS conceives a child, most of the herbs mentioned above should not be used during pregnancy, unless recommended by the patient’s healthcare provider.2 A few — including ginger, red raspberry leaf, echinacea, and partridge berry — have safe pregnancy profiles.10 As in most cases, readers are advised to consult their healthcare provider for more information.
- Polycystic ovarian syndrome (PCOS) fact sheet. Office on Women’s Health website. Available at: http://womenshealth.gov/publications/our-publications/fact-sheet/polycystic-ovary-syndrome.cfm#b. Accessed February 15, 2013.
- Romm A. Botanical Medicine for Women’s Health. St. Louis, MO: Churchill Livingstone; 2012.
- Goodman B. Infertility treatments may raise birth defect risk. WebMD Health News. May 5, 2012. Available at: www.webmd.com/infertility-and-reproduction/news/20120505/infertility-treatments-may-raise-birth-defect-risk. Accessed February 15, 2013.
- Maizes V, Low Dog T (eds.). Integrative Women’s Health. New York, NY: Oxford University Press; 2010.
- Stansbury J. The PCOS Health & Nutrition Guide. Toronto, Ontario, Canada: Robert Rose; 2012.
- Hudson T. Women’s Encyclopedia of Natural Medicine: Alternative Therapies and Integrative Medicine. Los Angeles, CA: Keats Publishing; 1999.
- van Die MD, Burger HG, Teede HJ, Bone KM. Vitex agnus-castus extracts for female reproductive disorders: a systematic review of clinical trials. Planta Med. November 2012; [epub ahead of print]. doi: 10.1055/s-0032-1327831.
- Armanini D, Mattarello MJ, Fiore C, Bonanni G, Scaroni C, Sartorato P, Palermo M. Licorice reduces serum testosterone in healthy women. Steroids. 2004;69(11-12):763-766.
- Dong quai (Angelica sinensis). Mayo Clinic website. Available at: www.mayoclinic.com/health/dong-quai/NS_patient-Dongquai. Accessed March 20, 2013.
- Hobbs C, Keville K. Women’s Herbs, Women’s Health. Loveland, CO: Botanica Press; 1998.
- Gladstar R. Herbal Healing for Women. New York, NY: Fireside; 1993.
- Jalilian N, Modarresi M, Rezaie M, Ghaderi L, Bozorgmanesh M. Phytotherapeutic management of Polycystic Ovary Syndrome: role of aerial parts of wood betony (Stachys lavandulifolia). Phytother Res. 2013. doi: 10.1002/ptr.4921.
- Kamel HH. Role of phyto-oestrogens in ovulation induction in women with polycystic ovarian syndrome. Eur J Obstet Gynecol Reprod Biol. 2013. doi: 10.1016/j.ejogrb.2012.12.025.
- Chen J, Tominaga K, Sato Y, et al. Maitake mushroom (Grifola frondosa) extract induces ovulation in patients with polycystic ovary syndrome: a possible monotherapy and a combination therapy after failure with first-line clomiphene citrate. J Altern Complement Med. 2010;12(12):1295-1299.
- Hudson T. Maitake mushroom extract and polycystic ovarian syndrome. March 31, 2011. Dr. Tori Hudson, N.D. blog. Available at: http://drtorihudson.com/botanicals/maitake-mushroom-extract-and-polycystic-ovarian-syndrome/. Accessed March 19, 2013.
- Raffone E, Rizzo P, Benedetto V. Insulin sensitiser agents alone and in co-treatment with r-FSH for ovulation induction in PCOS women. Gynecol Endocrinol. 2010;26(4):275-280.
- Nestler J, Jakubowicz D, Reamer P, Gunn R, Allan G. Ovulatory and metabolic effects of d-chiro-inositol in the polycystic ovary syndrome. N Engl J Med. 1999; 340:1314-1320.
- Nordio M, Proietti E. The combined therapy with myo-inositol and D-chiro-inositol reduces the risk of metabolic disease in PCOS overweight patients compared to myo-inositol supplementation alone. Eur Rev Med Pharmacol Sci. 2012;16(5):575-581.
- Galletta M, Grasso S, Vaiarelli A, Roseff SJ. Bye-bye chiro-inositol-myo-inositol: true progress in the treatment of polycystic ovary syndrome and ovulation induction. Eur Rev Med Pharmacol Sci. 2011;15(10):1212-1214.
- Myo-inositol versus D-chiro-inositol in the treatment of polycystic ovary syndrome and insulin resistance: evaluation of clinical, metabolic, endocrine and ultrasound parameters. ClinicalTrials.gov. Available at: www.clinicaltrials.gov/ct2/show/study/NCT01514942?term=inositol+pcos&rank=2. Accessed March 27, 2013.
- Unfer V, Carlomagno G, Rizzo P, Raffone E, Roseff S. Myo-inositol rather than D-chiro-inositol is able to improve oocyte quality in intracytoplasmic sperm injection cycles. A prospective, controlled, randomized trial. Eur Rev Med Pharmacol Sci. 2011;15(4):452-457.
- Fengang JM, Konarski P, Zou D, Stintzing FC, Zou C. Nutritional and medicinal use of cactus pear (Opuntia spp.) cladodes and fruits. Frontiers in Bioscience. 2006;11:2574-2589.
- Nidhi R, Padmalatha V, Nagarathna R, Amritanshu R. Effect of holistic yoga program on anxiety symptoms in adolescent girls with polycystic ovarian syndrome: A randomized control trial. Int J Yoga. 2012;5(2):112-117. doi: 10.4103/0973-6131.98223.
- Mavropoulos JC, Yancy WS, Hepburn J, Westman EC. The effects of a low-carbohydrate, ketogenic diet on the polycystic ovary syndrome: A pilot study. Nutr Metab. 2005;2:35.
- Johansson J, Redman L, Veldhuis PP, Sazonova A, Labrie F, Holm G, Johannsson G, Stener-Victorin E. Acupuncture for ovulation induction in polycystic ovary syndrome: A randomized controlled trial. Am J Physiol Endocrinol Metab. 2013 Mar 12. [Epub ahead of print].