SUMMARY OF TYPICAL CONSULTATION HISTORY: PCOS

The largest group of patients visiting Medical Herbalists are ladies presenting with menstrual and hormonal conditions, the most common presentation being Polycistic Ovarian Syndrome (PCOS). One of my patients visited me over a year. She was a 30-year old single woman living alone with no children. She held three jobs, including social work and writing; information on her third occupation was not released due to confidentiality.

Her menarche had been at 15 years of age and always distressing premenstrually. PCOS had first been diagnosed at 17 and she had been hirsute since 16 years of age. She had been prescribed Dianette for 1 year. 10 years before, the patient had consulted with a private Practitioner, where she had been successfully treated of premenstrual irregularity. After two years free of premenstrual symptoms, the condition relapsed but went untreated until the patient visited me. Between 18 and 22 years of age, the patient had been sexually active and had experienced pain on intercourse, which however had not recurred afterwards. She had never tried to conceive.

During the worst menstrual day, the patient would be confined to bed with pain in the abdomen, knees, hips and arms. On the first day, the patient would experience incomplete emptying of her bowels accompanied by diarrhoea. The pain would start 2 weeks before her menstrual cycle and disappear immediately after. She would also suffer from breast tenderness and swelling underthe armpits. Premenstrually, she would feel hungrier than usual and crave carbohydrates, cholcoate and other junk foods. Her cycle would typically last 4-5 weeks, although it had become more regular. Her bleeding would last 4 days. During the first day, there would be clots indicating heavy flow. She would also complain of acne, although this was never observed clinically.

At the first visit, the patient's diet had been deficient and her appetite poor, she had been feeling fatigued, despite sleeping over 8 hours. the patient's premenstrual pain had worsened since October 2005 and had been severe premenstrually.

The patient was monitored carefully. No gyneacological investigation had been carried out before her visiting a Herbalist. Then a smear and blood tests were requested and results were negative. On my advice, the patient had also asked her new GP for a a laparoscopy to rule out endometriosis. Blood tests continued to be normal but the GP did not deem it necessary to refer her for laparoscopy.

The patient had also presented with mood depression and had been feeling angry. Premenstrually, her mood would lead to clumsiness, tearfulness, "breaking lots of things" and a feeling that life "simply gets our of hand". I suspected that her mood depression may have been stirred up by psychodynamic therapy, which she had been attending three times per month. By her third visit to me, she had been dramatically happier and by the end of the treatment, she had been considerably cheerful; she had been pleased that she finally was not experiencing any premenstrual symptoms at all. She vaguely mentioned some positive life events that involved her occupation as a writer and looked radiant. Since then, the patient continued to be "eating well" and there was no sign of depression. Her PMS had also stopped. Hirsutism was no longer a problem and visit to the beautician for facial hair removal were no longer required. Reassement was carried out before discharge.

PROGNOSIS

The prognosis had been good from the start, although treatment required regular monthly visits for the first six months and continued to be monitored twice yearly since discharge. Had it been untreated, PCOS might have increased pain and then lead to infertility due to impairment of ovarian and tubal function and poor interaction with coital and sperm function with inappropriate immune responses between partners.

MANAGEMENT

Advice included eating more regularly and taking dietary supplements, in order to maintain the basal metabolic rate, as the patient's hands had been cold, particularly during episodes of panic attacks and tachycardia (sympathetic nervous system activation).

Immunomodulating, immunostimulating herbs such as Echinacea, Siberian ginseng and Chaste berry were prescribed, as endometriosis had not been ruled out and the patient had been feeling fatigued and presented with lingering chest infections occasionally. Prolactin-lowering and hormone balancing herbs were blended. Uterine and bowel spasmolytic, relaxant and analgesic herbs were given in a pain mixture.

Management was altered at each monitoring appointment to suit all symptoms, mood changes and patient's routines and taste.

RESPONSE

The patient had been regular and compliant in increasing the number of meals, despite not taking multivitamin and mineral supplements. She took her herbal prescriptions as instructed, except for the intial pain mix, due to its taste, which was then improved. Despite the improvement in the pain mix, the patient did not wish to take it. However, the patient's menstrual pain turned into painless discomfort by the end of six months and she had no premenstrual symptoms and no hirsutism (facial hair went away).

REFLECTION

There were challenges in obtaining precise detail from the patient, who tended to answer to questions vaguely and evasively. It was essential to maintain an open mind as to the reasons for the presenting depression, although severe dysphoric disorder (premenstrual syndrome) was clearly one of the reasons. The impact of the patient's life events was not measured. The patient might benefit from a course of neurolinguistic programming (NLP) to unblock stuck emotions and restore confidence, particularly following psychodynamic counselling.