Polycystic Ovarian Syndrome (PCOS) was originally described in 1935 by Stein and Leventhal as a syndrome manifested by amenorrhea, hirsutism,and obesity associated with enlarged polycystic ovaries. Physical and psychological effects of PCOS, particularly those related to weight gain and infertility, can lead to social stigma and mental health challenges.It is the most common endocrine disorder in a woman of reproductive age. Incidence of PCOS is rapidly increasing in recent few years. There are many reasons behind it but some leading are changes in lifestyle,excessive consumption of junk food,disturbed sleep etc.While consulting in Striroga OPD, majority of patients came with such issues with different patterns of clinical manifestations which further shifts on infertility. It a remarkable public health issue affecting women of reproductive age. Prevalence of PCOS is higher among some ethnicities and these groups often experience more complications, in particular related to metabolic issues.In Ayurveda, yonivyapada and jatiharini are mentioned as a group of female diseases and the symptoms mentioned there have some similarities with PCOD but pushpaghni jatiharini described by Acharya Kashyapa has got much resemblance with its main clinical features.This syndrome involves pitta, kapha, medas with ambuvahasrotas and artavdhatu, which are primarily considered during management. This article deals with to understand the conceptual aspects of PCOS and to know the Ayurveda Protocol for its managements.

Introduction:

Polycystic Ovarian Syndrome (PCOS) was originally mentioned by Stein and Leventhal in 1935 by as a syndrome with manifestation of amenorrhea, obesity, hirsutism and associated with enlarged polycystic ovaries. [1] Physical and psychological effects of PCOS, particularly those related to obesity and infertility, can lead to social stigma and mental health challenges. It is the most common endocrine disorder in a woman of reproductive age. Incidence of PCOS is rapidly increasing in recent few years. There are many reasons behind it but some highlightings are changes in lifestyle, Excessive consumption of junk food, disturbed sleep etc. Circadian rhythm disurption found in PCOS.[2] A major hormone in regulating circadian rhythm ,melatonin is increasingly recognized for its role in female reproduction.[3] While consulting in Striroga OPD majority of patients came with this PCOS with different patterns of clinical manifestations. Most of the time PCOS is the cause of Infertility. PCOS a significant public health issue affecting women of reproductive age. The prevalence of PCOS varies worldwide, influenced by diagnostic criteria, the population studied, and methodological differences among studies. Epidemiological studies have shown that the prevalence of PCOS can range from 6% to 20%, depending on the population studied and the diagnostic criteria used.[4] This heterogenous disorder is characterized by excessive androgen production by the ovaries mainly. PCOS is a multifactorial and polygenic condition. Diagnosis is based upon the presence of any two of the following three criteria (ASRM/ESHRE, 2003).1) Oligo and/or anovulation.2) Hyperandrogenism (clinical and/or biochemical).3) Polycystic ovaries.[5] Other etiologies (CAH, thyroid dysfunction, hyperprolactinemia, Cushing syndrome) are to be excluded. The incidence varies between 0.5–4 percent, more common amongst infertile women. It is prevalent in young reproductive age group (20–30%). In about 20% of normal women polycystic ovary may be seen. Pathology: Enlarged ovaries with increased volume > 10 cm 3 is seen typically . Stroma is increased. The capsule is thickened and pearly white in color. Presence of multiple (> 12) follicular cysts measuring about 2–9 mm in diameter are crowded around the cortex.[6] Clinical features-The patient complains of increasing obesity (abdominal – 50%), menstrual abnormalities (70%) in the form of oligomenorrhea, amenorrhea or DUB and infertility. Presence of hirsutism and acne are the important features (70%) and Virilism is rare.[7] The cause of PCOS is still unknown in modern science, but hyperandrogenism and insulin resistance play an important role for its occurrence. PCOS prevalence is higher among some ethnicities and these groups often experience more complications, in particular related to metabolic issues. Acharya Charaka has mentioned in charaksamhita Sutra Sthana 18/41-45 that there are aparisakheya (infinite) diseases. In Ayurveda PCOS is not directly mentioned but jatiharini and yonivyapada are described which represent diseases of female reproductive system and the symptoms mentioned there have some similarities with PCOS. Pushpaghni jatiharini described by Acharya Kashyap has got much resemblance with its main clinical features. This syndrome involves pitta, kapha, meda with ambuvahasrotas and artavdhatu, which are primarily considered during treatment. The psychological impact of PCOS, including increased rates of mood swings, depression, anxiety, and body image disturbances, highlights the importance of comprehensive care that addresses both the physical and mental health aspects of the syndrome. For this, ayurveda having better management protocol along with pathyapathya kalpana to balance biological clock. Agni Deepana and Aamapachana are basic treatment principles in management of PCOS. Treating PCOS is treating metabolism of body. Oral contraceptive pills and antidiabetic drugs like metformin give symptomatic relief but root cause of PCOS can be tackled by Ayurveda. Aacharya Charaka mentioned that to treat the disease based on dosha-dushya involvement. Aim of ayurveda is ‘Swasthasya swasthya rakshanam aatruasya vikara prashaman.’ So for PCOS ayurveda not only control it but prevent also by following Dinacharaya, Ritucharya. This article deals with to understand the conceptual aspects of PCOS and to know the Ayurveda protocol to manage it as it becomes the necessity in current era.

Aims and Objects:

1. To understand the Ayurvedic literature review of PCOS.
2. To study the etiological factors of PCOS, according to the Ayurvedic Samhitas and modern lifestyle.
3. To find out psychological disturbances in PCOS and its management through ayurveda.
4. To create awareness about PCOS and its prevention by following ayurveda.

Materials and Methods

 This is literature review study. For this study, various ayurvedic and modern medicinal textbooks, Research Articles, Internet Source are used. References are collected from textbooks.

PCOS According to Modern Science – [8]

Excessive androgen production by the ovaries is the main attribute of this diversified condition. Diagnosis of PCOS is based upon the presence of any two of the following three criteria (ASRM/ESHRE, 2003).

1)Oligo and/or anovulation.

2) Hyperandrogenism (clinical and/or biochemical).

3) Polycystic ovaries.

Other causes (CAH, thyroid dysfunction, hyperprolactinemia, Cushing syndrome) are to be excluded. The incidence varies between 0.5–4 percent, more common amongst infertile women. It is prevalent in young reproductive age group (20–30%) and may be seen in about 20% of normal women.

Pathology: Enlargedment of ovaries with increased Ovarian volume (> 10 cm 3), Stroma. Presence of multiple (> 12) follicular cysts measuring about 2–9 mm in diameter are crowded around the cortex. Thickening of tunica albuginea is seen histologically. The cysts are follicles at different stages of maturation and atresia. There is theca cell hypertrophy (stromal hyperthecosis). Patient may present with features of diabetes me llitus (insulin resistance).

Clinical features: The patient complains of increasing obesity (abdominal – 50%), menstrual abnormalities (70%) in the form of oligomenorrhea, amenorrhea or DUB and infertility. Important features are presence of hirsutism and acne (70%) and rare is virilism. Due to insulin resistance specific skin changes are observed (Acanthosis nigricans). Thickened and pigmented (grey brown) skin is seen. Nape of the neck, inner thighs, groin and axilla are commonly affected sites. In PCOS HAIR-AN syndrome is with characteristics hyperandrogenism, insulin resistance and acanthosis nigricans.

Investigations:

1) Ultrasonography of Pelvis—Ovaries are enlarged in volume (> 10 cm3). Increased number (> 12) of peripherally arranged cysts (2–9 mm).

2) Serum values:

Elevated levels of LH, estradiol and estrone, Andro-stenedione, serum testosterone, fasting insulin

and reduced Levels of SHBG.

3) Laparoscopy shows bilateral polycystic ovaries.

Pathophysiology

Exact pathophysiology of PCOS is not clearly understood. But following are the important heads to understand it.

Hypothalamic — Pituitary Compartment : Pulse frequency of LH is increased due to increased pulse frequency of GnRH. Due to the negative feedback effect of chronically elevated estrogen and the follicular inhibin FSH level is not increased but LH: FSH ratio is increased.

 Androgen excess: Main cause for excess production of androgens from the ovaries and adrenals is abnormal regulation of the androgen forming enzyme. The principal sources of androgens are Ovary, Adrenal, Systemic metabolic alteration.

 Anovulation: Follicular growth is arrested at different phases of maturation due to low level of FSH. Hypertrophy of theca cells is seen due to raised LH and excess androgens are produced either from theca cells or stroma.

Obesity and Insulin Resistance: Obesity (central) is marked as an important contributory factor. It is not only associated with excess production of androgens but also with reduced SHBG. It also induces resistance of insulin and hyper- insulinemia which in turn increases the production of gonadal androgen. Etiology of insulin resistance is unknown. Long-term consequences in a patient suffering from PCOS includes: The excess androgens (mainly androstenedione) either from the ovaries or adrenalsare peripherally aromatized to estrone (E1). There is concomitant diminished SHBG.

Possible late sequele of PCOS:

• Obese women (BMI > 30) are having high risk of developing diabetes mellitus (15%) due to Insulin resistance.
• Due to persistently elevated level of estrogens risk of developing carcinoma of endometrium.
• Risk of hypertension and cardiovascular disease as dyslipidemia (↓HDL,↑triglycerides, ↑LDL) is the most common metabolic abnormality in women with PCOS.
• Obsructive sleep apnea.

Management of PCOS needs detailed history of the patient. It depends on her presenting symptoms like menstrual issues, infertility, weight gain, hirsutism or complex symptoms. Patient counseling is also very important. Treatment is primarily targeted to correct the biochemical abnormalities. Weight reduction in obese patients is the first line of treatment. Body mass index (BMI) < 25 improves menstrual disorders, infertility, impaired glucose intolerance (insulin resistance), hyperandrogenemia (hirsutism, acne) and obesity. Weight reduction (2–5%) improves the metabolic syndrome and reproductive function. Management of hyperandrogenemia: Combined oral contraceptive pill (OCP)s are effective. Progestin decreases LH and estrogen enhance SHBG, lowering free testosterone level. Newer progestins (desogestrel) are best suited.Hirsutism is due to anovulation, high androgen and insulin levels, decreased production of hepatic SHBG and also due to hair follicles genetic sensitivity to androgens.

Metabolic syndrome: Hyper-insulinemia (insulin resistance) causes hyperandrogenemia. Insulin resistance is associated with diabetes mellitus, central obesity, dyslipidemia and hypertension. Metformin decreases weight and BMI and reduces LDL cholesterol, blood pressure and the risk of developing diabetes and increases insulin sensitivity.

Metabolic Syndrome (Diagnostic Criteria) – Presence of three abnormal findings out of the five-

• Triglyceride levels ≥ 150 mg/dl
• HDl-cholesterol < 50 mg/dl
• Blood pressure ≥ 130/80 mm Hg
• Fasting glucose ≥ 100 mg/dl
• Abdominal (waste circumference) obesity > 88 cm

Hyperinsulinemia contributes hyperandro-genemia in women with PCOS: Hyperinsulinemia

increases the risk of dyslipidemia, cardiovascular disease and diabetes mellitus. Insulin resistance is the principal abnormality to cause metabolic syndrome.Metformin is used as an oral insulin sensitizing.

Surgery: Laparoscopic ovarian drilling (LOD) is done for cases found resistant to medical therapy. Pregnancy rates following ovarian diathermy are higher. Bariatric surgery may be indicated in some PCOS women who are morbidly obese.

PCOS in Ayurveda-

In Ayurveda,it is difficult to consider direct correlation of PCOS with a specific disease. There is description of different gynaecological disorders under the heading of Yonivyapads, Arthava Vyapada and Beeja Dosha. PCOS is a disease of artavavaha srotasa. Symptoms of Diseases like Vandya, Nashtartava, Artavakshaya and Puspaghni Jataharini defined by Acharaya kashyapa can be related to PCOS at some extent. PCOS is of Bahudoshavastha condition. Aavarana is the main samprapti (pathogenesis) of PCOS. Kapha Medo-related dosha dushyasamurchana is seen in this condition. In PCOS numerous granthis are seen in the ovary. Due to sangha in srotas caused by guru and snigdha guna of kapha dosha granthis are formed. These granthis with a strong Kapha platform inhibit the aartava leading to artavarodha.[9] As it is a syndrome, the exact correlation is not possible, but the clinical symptoms of the disease can be correlated under the following heading the metabolic symptoms like obesity, Insulin resistance can be included under Sthoulya and Prameha. Hyperandrogenic symptoms such as acne and baldness can be correlated with Mukhadooshika and Khalathi respectively. Anovulation resulting in amenorrhoea or irregular menstrual cycle is described under the disease Vandhya and Pushpagni jaataharini by Acharya Kashyapa. Clinical symptoms like menstrual irregularities (amenorrhea) and bloating of the abdomen can be seen in Raktha Gulma .According to Ayurveda PCOS is a disease of artavavaha srotas with bahudoshavastha.Main pathogenesis occur in PCOS is aavarana.

Hetu -The aetiological factors include-

• Mithya Ahara vihara,
• Pradushtarthava dusthi, and
• Beeja dosha

Mithyahara including the consumption of fast food. Mithyahara,Virudhahara. As per the definition explained by Charakacharya, those food substances and their blends that encourage adverse action on the dhathus can be called Virudhahara.

Mithya vihara - The sedentary lifestyle along with improper diet, irregular sleeping patterns, and psychological factors such as stress, anxiety, and pressurized competition point to the Mithya vihara of modern society. The presence of these factors adds the impaired metabolism. Chronic anxiety and depression are the most psychological pattern in PCOS patients.

The word Pradushtarthava denotes the irregularities of the hypothalamic-pituitary-ovarian axis. In PCOS, alteration of the HPO axis occurs, and the manifested biochemical abnormalities Include high LH/FSH ratio, elevated androgen production, and high estrogen levels due to the peripheral conversion of androgens in adipose tissue, leading to the alteration in normal hormonal activity. Various chromosomal and genetic abnormality comes under the heading Beejadushti.

Samprapti - “Without the aggravation of Vata, the women’s Yoni does not get vitiated.[10]Vata is responsible for all movement and Kapha and Pitta doshas require Vata dosha for movement.Among all 5 types of Vata, Apana Vayu is responsible for the expulsion of Shukra, Arthava, Shakruth, Muthra, and Garbha. The action of Apana vayu gets blocked by the increase of Kapha dosha in the body. The barrier of Vatadosha subsequently blocks Pittadosha also. This vitiation interrupts the movement and conduction of hormones, which are thus unable to perform their actions.The major etiological factors like Atisnigdha, Abhishyanthi (high-calorie food and junk food) aharas, Diwaswapna, Alpa vyayama, etc vitiate kapha dosha. All those hetu lead to the impaired function of Agni at various levels (Jataragni, Dhatwagni, and Bhuthagni). This Agnimandya lead to the formation of Asamyak pachitha ahara rasa (Ama) in the body. The vitiated Kapha and ama rasa increase the Snigdhamsha of the body and causes Srothorodha that cause impairment in normal functioning of vata.The vitiated Vata and Kapha cause avarana of Artavavaha Srotas that causes to Artavanasha.

Dosha Dushya Involvement –

Vata vitiation - Arthava Vaha Srothas - irregular menstrual cycle

Pitta vitiation - Acne,hirsutism and hormonal imbalances

Kapha vitiation – weight gain

Rasa - Srothorodha, Klaibya, Agni Mandhya, Kapha Vridhi Lakshanas like Gaurava, Agnisada, etc.

Rakta- Asrigdara, Vyangam, Gulma

Mamsa- Udara Gouravam

Meda - Athisthoulya, Purvarupa of Prameha

Asthi-Kesa Loma Smasru Dosha

Shukra- Vandhyatwa

Aartava - Vandhyatwa, Arthava Naash. [11]

Purvaroopa -

 The word Purvaroopa refers to a stage when the mild signs and symptoms of the disease manifest, that is the primary stage before a full-blown manifestation. So, slight irregularities in the menstrual cycle, weight gain, mild acne, etc. can be included under Purvaroopa as it gives idea about the upcoming PCOS.There is variation in symptoms.

Roopa –

Clinical symptoms like menstrual irregularities (amenorrhea), and bloating of the abdomen can be seen in Raktha gulma.[12] Anovulation resulting in amenorrhea or irregular cycles is described under the disease Vandhya and Pushpagni jaataharini by Acharya Kashyapa[13]. Menstrual irregularities such as oligomenorrhea, and amenorrhea are included in various Yonirogas (Vandhya) and Arthava Vyapaths (Arthavakshaya, Nashtarthava, Asrigdara).[14] Hyperandrogenic symptoms such as acne and baldness can be correlated with Yuvaan pitika and Khalitya respectively. Obesity, described as Sthoulya can be included in Santharpanajanya rogas.[15] Hirsutism is described as Athilomatha under Ashtaninditha Purusha lakshana by Charakacaharaya. Sthula loma described in Pushpagni jaataharini also refers to hirsutism and acanthosis can be correlated with Karshnya. Hyperinsulinaemia, commonly leading to Type 2 diabetes mellitus is described under Prameha.[16]

Sadhyasadhyata -

  It is stated in ayurvedic literature that the diseases arising in Abhyanthara Rogamarga are Sukhasadhya, Madhyama Rogmarga are Asadhya and Bahya Rogmarga are krichrasadhya.  PCOS is a syndrome with a complex set of signs and symptoms arising in all three Rogamargas so it’s Krichhasadhya vyadhi.Although PCOS is not a completely curable disease, the adverse features of the disease can be managed with medications and lifestyle modifications. So, it can be involved in the group of yapyaroga also.

Management protocol according to Ayurveda -

The main aim of Chikitsa is Samprapti Vighatanam. As PCOS is primarily concerned with Stri beeja formation and ovulation and to some extent medodhatu, much attention should be given to these while treating the conditions.

Treatment Principle are-

• Aamapachana
• Koshtha Shudhhi
• Balancing Tridosha

The management approach to PCOS should focus on:

• Correction of agnimandya at jataragni and dhatwagni level by Deepana (carminatives) and Pachana (digestives) drugs.
• Alleviating sroto avarodha (shodhana) purificatory therapies based upon the grade of doshic vitiation and site of affliction).
• Regularization of apana vata (vatakaphahara medicaments)
• Samksepatha: kriyayogo nidana parivarjanam”.[17]
• Nidan parivarjana: Avoidance of kaphakara ahara & vihara.

Shodhana -

“Tatra samsodhanam aagneyaanam cha dravyaanam vidhivat upayoga [18].

For minimising kapha related granthis in ovary and to correct avarana and vata vaiguna lekhana basti,Erandmuladi shodhana basti, Uttarbasti - Phulghrita, kasisadi taila, sahchar taila, bala taila etc. As PCOS is a condition of bahudoshavastha and the doshas are vitiated extremely so they must be ejected out through the nearest external opening with the help of Panchakarmas and by the use of Agneya Dravayas.

It clears the Srotas, purifies the dhatus and produces Vatanulomana.

Shamana Chikitsa –

• Phalghrita - corrects hormonal imbalance, regulates artava.
• Kanchanar guggulu - indicated in granthi.
• Kuberaksha vati - lasuna, latakaranj -indicated in granthi.
• Rajaha pravarthini vati - kumari, kasis, hingu- Aartavpravrthak
• Chandraprabha vati – for obesity, metabolic disorder, corrects vata and pitta vitition.
• Gokshuradi guggulu– corrects apana vayu.
• Punarnava mandoor – works in obesity, metabolic disorders.

 Some local therapies like udvartana, avgaha sweda, shirodhara, shiropichu also play important role in management of PCOS. In PCOS management along with medications meditation and yogasana also equally important to maintain biological clock. There are some asana which are better for managing PCOS like Setubandhasana (Bridge), Bhujangasan (Cobra), Ardhamatsyendra asana (Seated half spinal twist), Dhanurasana (Bow), Natrajasana (Supine dancing shiva), Surya namaskar (Sun salutations), Chakki Chalanasan (Churning mill pose) [19].

Discussion:

PCOS is well managed by medications and lifestyle modifications by following Ayurvedic Paricharya.Exact correlation of PCOS is not found in Ayurvedic classical texts. The various symptoms associated with PCOS show similarities with Raktajgulma, Prameh (Diabetes), Sthoulya (Obesity), etc.Pushpagni Jaataharini described by Aacharya Kashyapa showing similarities with this disease. Vandhya Yonivyapada, Nashtarthava, Arthavakshaya mentioned in Susrutha Samhita can also be taken into account. Avarana of Artavavaha Srotas due to vitiated Vatha and Kapha leading to Arthavanaasha and Vandhyatvam can be considered as the basic underlying samprapti (pathology). Shodhana Chikitsa followed by aamapachana balances menstrual irregularities.

Conclusion:

PCOS cannot be directly correlated to single disease entity mentioned in Ayurveda classics. Amenorrhea in PCOS can be correlated as Nashtarthava, Yathochita kala adarsana (delayed cycles) and Alpata (decreased quantity) as Arthavakshaya. Anovulation resulting in Amenorrhoea (Artava kshaya and nashtarva) or Irregular menstrual cycles is described under the Vandhya yonivyapada. Sthoulya and Prameha Poorvaroopa lakshanas are also seen in PCOS. PCOS is said to Bahudoshaavastha vyadhi. Involvement of tridosha and dhatu - Rasa, Rakta, Mamsa, Meda, Asthi and Arthava vaha srotases are seen with their dushti lakshanas. Avarana of Artavavaha Srotas due to vitiated Vatadosha and Kaphadosha leading to Arthavanaasha and Vandhyatvam can be considered as the basic underlying pathology.

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