Analogy: Flesh of the apple	Context: Put the presenting complaint into context to understand the disease
AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS	CLIENT RESPONSES
Family health
Has anyone in your family had these problems?	Not that I can think of.
Recreational drug use
How much alcohol would you consume a week?	Maybe 6 to 8 glasses a week, mostly on the weekend.
Functional disease
Do you strain to pass at least 1 in 4 bowel motions and are then left feeling like the evacuation is incomplete or that there’s an obstruction? (functional constipation)	Yes. I seem to have to strain often to pass a bowel motion. But it does feel complete when I pass a bowel motion.
Infection and inflammation
Have you used any vaginal sprays, douches or had several bubble baths recently? (chemical vaginitis, vulvovaginitis)	No, I have not indulged enough in that kind of thing!
Supplements and side effects of medication
Are you taking any supplements or medications?	Just a multivitamin. I thought I should take something since my diet is not good at the moment.
Endocrine/reproductiveTell me about your menstrual cycle.	Gia explains that her periods have become irregular and she is never really sure when it is going to come, when Gia develops a backache or stomachache she realises her period is probably going to come in a couple of days.
Stress and neurological disease
How are you managing your stress at the moment?	Mostly with chocolate! My boyfriend is really great, he’s a great de-stressor.
Eating habits and energy
Tell me about your diet and energy levels.	Gia describes a diet that is high in refined carbohydrates, sugar and caffeine. She does have some whole foods and vegetables but not as much as she knows she should have. She says she finds her energy levels fluctuate, but she finds coffee or cola drinks help with that.

TABLE 5.3 CORE

Analogy: Core of the apple with the seed of ill health	Core: Holistic assessment to understand the client
AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS	CLIENT RESPONSES
Daily activities
Describe your daily routine.	When I get up I have a coffee and cereal and then I either go to uni or I study at home. I try to go out for a jog or swim, but haven’t really done much recently. My boyfriend comes over in the evenings 3–4 times a week and I spend all weekend with him if I don’t have to work on an assignment.
Family and friends
What about family and friends?	I haven’t seen much of anyone in the last few months. I try and catch up with my family every 3 or 4 weeks, and talk to mum and dad on the phone a couple of times a week. My friends are understanding and I try to catch up with them on the weekends if I can.
Action needed to heal
How do you hope I can help you?	I thought you might be able to tell me how to improve my diet and lifestyle. Maybe you have some tablets that could help too.
Long-term goals
What are your long-term goals?	Finish uni and have a holiday! Then get a job teaching. Maybe in four or five years if things go well we might try for a baby. I’d like to get my hormones sorted out before we try for one.

TABLE 5.4 GIA’S SIGNS AND SYMPTOMS [2, 6]

Results of medical investigations

No medical tests have been carried out.

TABLE 5.5 UNLIKELY DIAGNOSTIC CONSIDERATIONS [2, 7–10]

Conditions and causes	Why unlikely
FAMILY HEALTH
Familial or idiopathic hirsutism	Excess hair growth would not be typically androgenic, appearing on hormonally influenced areas of the body where hair will grow, such as the face, armpits, abdomen, chest and thighs; no known family history of excess hair growth
OBSTRUCTION AND FOREIGN BODY
Polycystic renal disease: lower abdominal and back discomfort	Urinalysis is clear, no high blood pressure
INFECTION AND INFLAMMATION
Chronic salpingo-oophoritis: irregular cycle; can be minimal or excessive menstrual bleed	Usually congestive dysmenorrhoea is the predominant symptom; associated with purulent discharge, fever, period pain and abdominal pain
Cystitis	Urinalysis NAD
ENDOCRINE/REPRODUCTIVE
Diabetes: anovulatory cycles	Urinalysis NAD
Primary dysmenorrhoea: lower abdominal pain, can get worse with menstrual cycle	Period pain usually starts when menses first begins and is often associated with no pelvic abnormality, nausea, vomiting, headache or dizziness
Secondary dysmenorrhoea: acquired due to pathology; period pain begins several years after menarche and due to a pelvic abnormality	Menstrual bleed is presenting as painless
Twisted uterine fibroids and polyps: twisted fibroids can cause symptoms of severe dysmenorrhoea, heavy bleeding, back pain and sometimes vaginal discharge	Usually maintains normal cycle unless submucosal or nearly extruded; causes uterine enlargement; usually causes menorrhagia (blood loss of 80 mL per day and lasting more than 7 days); fibroids form due to excess oestrogen
Premenstrual syndrome: pain in the abdomen before menses	Experiences premenstrual mood changes, feels teary, bloated and swollen 1–12 days before period; experiences a dull pelvic ache, abdominal bloating
Ovulatory bleed: have bleed mid-cycle as well as regular menses and ovulation has occurred	Feels emotional, premenstrual symptoms such as ovulation pain (mittelschmerz) and mood changes; usually spotting or light bleed at time of ovulation, regular cycle; check basal body temperature because it will be biphasic and fluctuate, indicating ovulation has occurred

Case analysis

TABLE 5.6 POSSIBLE DIFFERENTIAL DIAGNOSIS

Not ruled out by tests/investigations already done [2, 7–11, 59, 60]
CONDITION AND CAUSES	WHY POSSIBLE	WHY UNLIKELY
CANCER AND HEART DISEASE
Ovarian, pituitary or adrenal tumour	Will affect androgen levels, produce symptoms of irregular cycles, lower abdominal pain, acne, increased facial hair, depression, weight gain	No changes in smell or taste; no headaches mentioned indicating a brain tumour
Uterine cancer	Vaginal discharge	Usually brown discharge
Cervical cancer	Vaginal discharge, sexually active	Need to ask if the pain/blood is experienced on intercourse and the date of the last pap smear; vaginal discharge can contain blood
Adult-onset and congenital adrenal hyperplasia/adrenal tumour: can cause primary and secondary amenorrhoea; anovulatory cycles	Usually presents with severe acne and hirsutism; can present with anovulatory irregular menstrual bleeding	Check if rapid development of symptoms and how severe virilisation symptoms are; accompanied by severe virilisation such as frontal balding and enlarged clitoris
TRAUMA AND PRE-EXISTING ILLNESS
Congenital disorders (spina bifida, scoliosis, spondylolisthesis)	Lower back pain	Back pain only mentioned prior to menstrual period
Trauma (strains, sprains, tear, herniated disc, fracture, disc prolapse)	Lower back pain
OBSTRUCTION AND FOREIGN BODY
Intestinal obstruction (bowel cancer, adhesions, hernias, faecal impaction with overflow)	Abdominal distension and pain constipation	No vomiting, abdominal pain associated with menstrual cycle
FUNCTIONAL DISEASE
Functional constipation	Has 3 or fewer evacuations a week; not drinking enough water, high caffeine intake, not enough fruit, vegetables in diet, lack of exercise, stress	Need to check if more than 1 in 4 bowel motions is lumpy and hard, and causes strain, a feeling of incomplete evacuation or blockage; need to check if manual help is needed to facilitate a bowel motion passing
Faulty posture	Possible if sitting for long periods of time studying
INFECTION AND INFLAMMATION
Appendicitis/Meckel’s diverticulum	Intermittent lower abdominal pain, constipation; common age group	If pain becomes acute it could be a possible diagnosis
Pelvic inflammatory disorder: abdominal pain, could be from a sexually transmitted disease	Purulent vaginal discharge, sexually active, abdominal pain; irregular periods, lower backache	Unsure whether vaginal discharge is offensive, and unclear at this stage if there is pelvic pain; no fever; need to clarify if there is any pain on sexual intercourse; physical exam will indicate whether pain on motion during physical examination
Acute and chronic cervicitis: Chlamydia trachomatis, Neisseria gonorrhoea, herpes simplex virus	Vaginal discharge can be produced by cervicitis without vaginal infection; can be profuse discharge with lumbosacral backache	Need to define if the pain is experienced on intercourse associated with purulent discharge; physical exam will indicate whether pain on motion during physical examination
Chlamydia: can be asymptomatic and cause pelvic inflammatory disorder	Sexually active with new boyfriend; vaginal itching not a common symptom	Need to establish if mucopurulent cervicitis is occurring; increased frequency of urination not reported; a physical exam will indicate whether pain motion during physical examination; vaginal discharge usually yellow in colour
Gonorrhoea	Vaginal discharge and abdominal discomfort vaginal discharge can be produced by gonorrhoea without vaginal infection; sexually active with new boyfriend; vaginal itching not a common symptom	Need to define if has had any recent rectal infections, pain on walking or climbing stairs; physical exam will indicate whether pain on motion during physical examination; vaginal discharge usually yellow in colour
Candidiasis (vaginal discharge, sexually active, would be detected when doing a pap smear)	Vaginal discharge, sweet cravings; constipation; Candida is common cause of vaginal discharge in adult women	Need to establish if Gia experiences external pain on urination and whether vaginal discharge has strong odour; vaginal discharge can be curdy (most common in yeast infections), recurrent and chronic episodes; symptom of vulvovaginal itching (most common in Candida infection); physical exam may indicate vulval inflammation
Inflammatory bowel disease	Abdominal and back pain prior to passing a bowel motion	No blood or mucus or episodes of diarrhoea reported; need to clarify if the abdominal pain is relieved when passing a bowel motion
Inflammatory lower back pain (fibromyositis, osteomyelitis, spinal, tubo-ovarian or rectal abscess, myelitis, endometriosis, cystitis, ankylosing spondylitis)	Lower back pain	Still need to be investigated
Trichomoniasis: a flagellated protozoon that causes vaginitis and urethritis, predominantly sexually transmitted; trichomonal vaginitis often associated with gonococcal or bacteroides cervicitis	Common cause of vaginal discharge in adult women; sexually active; common in women of child-bearing age	Usually severe local irritation and itching in vagina; vaginal discharge is usually frothy, profuse, white-greyish green, smelly discharge; increased frequency of urination not reported; can produce vaginitis with coexisting urethritis that causes pain on urination
Bacterial vaginosis: increase in aerobic bacteria (Gardnerella vaginalis) and decrease in lactobacilli	Vaginal discharge; common cause of vaginal discharge in adult women; common during reproductive years; itching not a prominent symptom; usually no symptoms of vaginal inflammation	Need to establish if vaginal discharge is offensive watery grey-white discharge, changes normal flora of the vagina; discharge is homogeneous; no increased frequency of urination reported
ENDOCRINE/REPRODUCTIVE
Ectopic pregnancy	Irregular periods; can present with no pain (rare) and can leak over several days slowly; may be missed; common cause of secondary amenorrhoea, purulent vaginal discharge	Usually associated with severe and acute abdominal pain, abdominal fullness, increased desire to urinate; may have signs of fever and dull headaches
Pregnancy [65]	Irregular periods; missed periods; most common cause of secondary amenorrhoea; can present with vaginal discharge and pelvic/abdominal pain	Can present with fever; may have signs of breast tenderness and may have morning sickness
Ovarian disease: premature menopause often due to autoimmune disease	Menses beginning to change; can present with symptoms of menopause and irregular periods	No hot flushes
Polycystic ovarian syndrome (PCOS): extremely common cause of secondary amenorrhoea; anovulatory cycles [59, 60]	Irregular menstrual cycles, lower abdominal pain, hormonal acne, increased facial and body hair (hirsutism), sugar cravings, weight gain	Check if symptom development has been slow and steady; may have thinning of hair on the head (like men do) called androgenic alopecia
Hypothyroidism: cause of secondary amenorrhoea due to hyperprolactinaemia and endocrine disorder; anovulatory cycles	Weight gain, irregular periods, constipation, increased facial and body hair (hirsutism), weight gain, constipation	No skin and hair changes mentioned; no significant fatigue, temperature intolerance or visible goitre noted; no significant depression mentioned
Cushing’s syndrome: causes amenorrhoea, irregular menstrual cycles	Irregular menstrual cycles, increased facial hair, weight gain	Check if symptom development has been rapid; no moon-shaped face, frontal balding or hypertension and oedema; no significant depression mentioned; urinalysis NAD and no indication of glucose intolerance or diabetes which can be associated with Cushing’s syndrome
Adenomyosis: benign invasion of endometrium (inner layer of uterus) into myometrium (thick muscle layer of uterus); can be associated with endometriosis, pregnancy, abortions, caesarean sections, tubal surgery	Heavy bleeding common	Common complaint that often does not cause symptoms; more often occurs between the ages of 30 and 50; can cause painful periods due to excess oestrogen
Endometriosis	Irregular periods; lower back and abdominal pain prior to menstrual bleed; can have symptoms of vaginal discharge	No significant pelvic pain or pain on menstrual bleed reported; no bleeding from the bowel; usually brown discharge with associated abdominal and pelvic pain
Dysfunctional uterine bleeding (DUB): endometrial hyperplasia, PCOS, from taking exogenous oestrogen; endocrine dysfunction not associated with inflammation, tumour or pregnancy; anovulatory hormone related bleeding is most common	Usually causes unpredictable frequency and amount of bleeding; menorrhagia (heavy bleed with regular cycle) common but interval between periods is usually shorter	No use of exogenous oestrogen reported
Anovulatory bleeding: irregular bleeding that appears to be menstrual although no ovulation has occurred; can be associated with both short and long cycles [63]	Irregular cycle; no significant premenstrual symptoms reported to show evidence of regular association with menses cycle; bleed is painless; blood volume can be excessive but irregular; physical findings will often include hirsutism, acne, and indicate PCOS	Check if bleed is unexpected; check basal body temperature, if anovulatory it will not fluctuate (monophasic)
Oestrogen-withdrawal bleeding: causes intermenstrual bleeding; occurs when the endometrium proliferates and becomes unstable when oestrogen drops below threshold; can happen outside of the secretory phase or in the absence of progesterone	Common cause of irregular periods in reproductive years, especially if ovulation has not occurred; menstrual bleeding is prolonged and profuse when does occur	Need to investigate if Gia experiences pain when bleeding as this is not usually present with oestrogen withdrawal [64]
Progesterone-withdrawal bleeding: only occurs when there is an oestrogen-primed endometrium; can occur when oestrogen therapy continued and progesterone stopped; also when progesterone is administered to test endogenous oestrogen	Irregular menstrual bleed often present in conditions such as PCOS
Oestrogen-breakthrough bleeding – 1st type: when oestrogen levels are low but constant causing sections of endometrium to degenerate	Intermenstrual bleed; common when have PCOS	Need to investigate if she experiences any spotting of blood [64]
Oestrogen-breakthrough bleeding – 2nd type: oestrogen levels are well above threshold causing endometrium to become hyperplastic and outgrow blood-borne hormone supply	Causes degeneration of endometrium with prolonged and irregular bleeding	More common in oestrogen-based tumours
Ovarian cyst	Lower abdominal pain, irregular periods	Ovarian cysts almost never cause heavy menstrual bleeding
Physiologic leukorrhoea: must be in absence of yeast infection, Trichomonas	Vaginal discharge; discharge usually thick, greyish white, no odour but profuse; usually no itching associated	More common in girls beginning their menarche
AUTOIMMUNE DISEASE
Rheumatoid spondylitis	Lower back pain; can be early signs of rheumatoid arthritis	Need further investigation
STRESS AND NEUROLOGICAL DISEASE
Causal factor: Stress	Constipation, dietary changes, increased sugar cravings, lack of exercise
New sexual relationship	Vaginal discharge, pregnancy, irregular periods	Check if using contraception
EATING HABITS AND ENERGY
Causal factor: Diet: Eating more chocolate, carbohydrates, lack of water, excess caffeine	Insulin resistance connection with symptoms of PCOS, constipation, increase stress	Need to clarify dietary changes and duration of changes
Causal factor: Lack of exercise	Affect insulin resistance, PCOS, weight gain, stress, lower back ache

TABLE 5.7 DECISION TABLE FOR REFERRAL [2, 7–10, 13]

Complaint	Context	Core
Referral for presenting complaint	Referral for all associated physical, dietary and lifestyle concerns	Referral for contributing emotional, mental, spiritual, metaphysical, lifestyle and constitutional factors
REFERRAL FLAGS	REFERRAL FLAGS	REFERRAL FLAGS
• Hirsutism associated with menstrual change and other virilising symptoms such as acne

• A menstruating woman of any age can bleed from pregnancy complications

• Irregular bleeding in menstrual cycle

• Change in volume of menstrual bleed

• Purulent vaginal discharge

• Abdominal and lower back discomfort prior to menstrual bleed

• Stress building up due to studies

ISSUES OF SIGNIFICANCE ISSUES OF SIGNIFICANCE ISSUES OF SIGNIFICANCE

Nil

• Pattern of premenstrual symptoms have stopped indicating lack of ovulation

• Bowel motion less than three times a week

• Increased weight gain and acne with associated menstrual changes

• Excess caffeine foods

• Lack of exercise

• New boyfriend and sexual relations

• New relationship may have potential to effect Gia’s studies

• Excess body waxing due to hirsutism

REFERRAL REFERRAL REFERRAL

• Medical investigation to rule out serious endocrine causes of hirsutism and symptoms of virilisation

• Medical investigations for change in menstrual cycle, abdominal and lower back discomfort

• Musculoskeletal assessment for lower back pain

• Test for sexually transmitted diseases

• Education about contraception options

• Dietary assistance to balance food intake

• Massage for relaxation

• Student counsellor for time management issues

TABLE 5.8 FURTHER INVESTIGATIONS THAT MAY BE NECESSARY [1, 2, 6–12, 65]

TEST/INVESTIGATION	REASON FOR TEST/INVESTIGATION
FIRST-LINE INVESTIGATIONS:
Examine genitalia and note secondary sex characteristics	May indicate functional or endocrine disorder
Pelvic, vaginal, abdominal examination	Check for bulging uterus, ovaries can be palpable in PCOS, abdominal rebound tenderness, overactive bowel sounds, genital deformities, signs of trauma
Musculoskeletal examination	Back strain, trauma, deformities, inflammation
Human chorionic gonadotropin (HCG) blood test/radioimmunoassay (RIA)	Pregnancy, ectopic pregnancy
Vaginal smear	Evaluation of cervical mucus will indicate if ovarian oestrogen is being produced
Cervical smear	Detect cervical cancer
CA-125 serum marker	Ovarian cancer, endometriosis, pelvic inflammatory disease
Chlamydia cervical culture Cervical gonorrhoea culture	Sexually transmitted diseases
Full blood count	Rule out infection, tumour, inflammation, anaemia
Blood lipids	Increased possible risk for cardiovascular disease connected with PCOS [26–29]
Progesterone level	Test 7 days before menstruation to determine if ovulation has occurred; low serum progesterone level in anovulatory cycles
Oestradiol	Normal: PCOS, weight loss, excess exerciseRaised: pregnancy, ovarian tumour, testicular tumour, adrenal tumourLow: PCOS, polycystic ovarian disease, ovarian failure, anorexia nervosa, weight loss, excess exercise, hypothyroidism, Cushing’s syndrome, adrenal hyperplasia, menopause, Turner’s syndrome, failing pregnancy, fetal death
Oestrone	Elevated in PCOS due to peripheral conversion
FSH (follicle-stimulating hormone)	Normal: PCOS, pregnancy, anorexia, weight loss, excess exerciseRaised: ovarian failure, menopauseLow: polycystic ovarian disease, anorexia, weight loss, excess exercise, hypothyroidism, Cushing’s syndrome, adrenal tumour/hyperplasia
LH (luteinising hormone): due to pulsatile action of this hormone it may not be accurately measured on one random sample	Normal: pregnancy, anorexia, weight loss, excess exerciseRaised: PCOS, polycystic ovarian disease, ovarian failure, menopauseLow: anorexia, weight loss, excess exercise, hypothyroidism, Cushing’s syndrome, adrenal tumour/hyperplasia
PRL (prolactin): common in secondary amenorrhoea to be raised	Normal: ovarian failure, anorexia, weight loss, excess exercise, adrenal tumour/hyperplasiaRaised: PCOS (mildly), hypothyroidism, Cushing’s syndrome, pregnancy, amenorrhoeaLow: pituitary destruction from tumour
Testosterone	Normal: ovarian failure, anorexia, weight loss, excess exercise, hypothyroidism, pregnancyRaised: PCOS, Cushing’s syndrome, adrenal tumour/hyperplasia, testicular tumour, ovarian tumourLow: corticosteriod use
SHBG (sex hormone-binding globulin)	Low SHBG would indicate the presence of elevated levels of free androgens
Thyroid function testTSH, T4, T3	TSH (thyroid-stimulating hormone) increased in hypothyroidism
Fasting blood glucose test	Raised levels can indicate diabetes mellitus, Cushing’s syndrome
HOME TESTS:
Basal body temperature	Normally drops 24–36 hours after menses begins; with endometriosis there is often a delay in basal body temperature to the second or third day of menses; a decrease indicates preovulation and an increase of 5 degrees occurs after ovulation; monitors thyroid function
Ovulation prediction kits	Detects increase in urinary luteinising hormone (LH) excretion 24–36 hours prior to ovulation
IF NECESSARY:
Progesterone withdrawal test	To determine if oestrogen is being produced in the body
17-hydroxyprogesterone	Elevated in congenital adrenal hyperplasia (classic early onset) and after stimulation tests can reveal late onset
Androgens: androstenedione and dehydroepiandrosterone sulphate	Elevated in PCOS and significantly so in congenital adrenal hyperplasia and virilising tumours; androstenedione is a precursor to cortisol, aldosterone, testosterone and oestrogen; will indicate possible adrenal tumour, ovarian tumour or Cushing’s syndrome
Serum cortisol blood test	Will determine Cushing’s syndrome possible adrenal tumour and stress levels
Abdominal and pelvic x-ray/ultrasound	Most accurate diagnosis of PCOS, ovarian mass, ovarian cyst or tumour, retroverted uterus, tubo-ovarian abscesses, fibroids, trauma; intestinal obstruction
Laparoscopy and biopsy/culdoscopy	Primary diagnostic technique for endometriosis by visualising the lesions
Endometrial, vaginal and cervical biopsies	Detect cancer; during luteal phase (10–12 days after ovulation) to determine inadequate luteal phase production or action of progesterone
Transvaginal ultrasonography	To determine cause of excess and random menstrual bleeding (menometrorrhagia) such as dysfunctional uterine bleeding or cancer
Brain scan CT/MRI	Pituitary tumour
Back x-ray, CT scan and MRI	Degenerative disc disease, disc prolapse, ankylosing spondylitis, Paget’s disease, osteoporosis

Confirmed diagnosis

Gia and polycystic ovarian syndrome with anovulatory menstrual cycle and physiologic leukorrhOea

Gia is 24 years of age and has come to the clinic for help with a series of symptoms associated with an irregular menstrual cycle. Gia is most concerned about acne, increasing facial and body hair, a vaginal discharge and a change to premenstrual symptoms. Gia is coming to the end of her studies to be a teacher and admits her current lifestyle includes a lot of computer work, lack of exercise, quick meals and consuming more chocolate, cola and energy drinks to get through. She has been craving sugar and has gained weight in the past seven months. Gia has a new boyfriend and enjoys seeing him up to four evenings a week. She is looking for alternative approaches to the oral contraceptive pill for helping her menstrual symptoms.

Gia was referred for a series of medical investigations and has been diagnosed with polycystic ovarian syndrome. Gia has classic symptoms of amenorrhoea, lower abdominal pain, backache, hormonal acne, sugar cravings, weight gain and increased facial and body hair (hirsutism). Multiple cysts develop on the ovaries causing increased production of androgens. Due to low levels of follicle-stimulating hormone, excess androgens are converted to testosterone rather than oestrogen. PCOS is a metabolic condition commonly associated with insulin resistance and glucose intolerance. Due to increased levels of insulin there is a decrease in SHBG, which binds increasing free androgens. A propensity to gain weight and develop obesity will make the underlying androgen increase and insulin resistance worse.

Amenorrhoea and oligomenorrhoea associated with symptoms of virilisation, such as acne and hirsutism, develop slowly and steadily shortly after menarche for many young women. Symptoms of PCOS can begin to become very uncomfortable in the second and third decade, affecting fertility and can influence the development of hypertension, hyperlipidaemia and cardiovascular disease. It is believed that a majority of women who do not ovulate regularly have polycystic ovarian syndrome.

General references used in this diagnosis: 2, 7, 9–11, 59, 60, 62

Prescribed medication

• Oral contraceptive pill [61]

Gia wants to try natural therapies to correct her hormonal balance at this stage. In view of the recommendation to take the oral contraceptive pill, it is important to work collaboratively with Gia’s doctor to ensure her condition is monitored. Her treatment program should be reviewed in eight weeks and then again four to six weeks later. If no change has occurred after 12–16 weeks Gia should be encouraged to consider other treatment options.

TABLE 5.9 DECISION TABLE FOR TREATMENT (ONCE DIAGNOSIS IS CONFIRMED)

COMPLAINT	CONTEXT	CORE
Treatment for the presenting complaint and symptoms	Treatment for all associated symptoms	Treatment for mental, emotional, spiritual, constitutional, lifestyle issues and metaphysical considerations
TREATMENT PRIORITY	TREATMENT PRIORITY	TREATMENT PRIORITY
• Dietary recommendations to support hormonal balance and improve glycaemic control, which is essential in managing PCOS • Lifestyle recommendations to improve glycaemic control and control PCOS symptoms • Physical treatment suggestions to help improve hormonal balance • Herbal tonic or tablets to support ovarian function and hormonal balance • Herbal tea to support hormonal balance and glycaemic control • Supplemental nutrients to improve glycaemic control

• Dietary recommendations to improve nutrition, general health and to reduce the risk of type 2 diabetes and cardiovascular disease

• Supplemental nutrients to improve nutrient and antioxidant status, as well as to support cardiovascular health

• Recommendation for Gia to lose weight to improve general health and reduce the risk of type 2 diabetes and cardiovascular disease

• Lifestyle recommendations to help reduce Gia’s stress levels

• Herbal tonic and tea containing nervine and adaptogenic herbs to help support Gina’s stress response

• Supplemental multivitamin to help support Gia’s stress response

NB: Blood pressure and serum potassium should be monitored while Gia is taking the herbal tonic or tablets due to licorice content; dandelion leaf has been added to the herbal tonic and tea to reduce the risk of hypokalaemia and hypertension [14, 19, 20]; dietary recommendation to reduce sodium intake and increase potassium intake while taking herbal tonic or tablets [14, 19, 20]

• Review use of chaste tree if menstrual irregularity worsens [14]

• Ensure Gia is using appropriate contraception while taking the herbal tonic or tablets due to pregnancy contraindications for schisandra [23, 24] and thuja [23]

• If Gia decides to try the oral contraceptive pill, a review of her herbal medicine will be required to ensure there are no negative drug/herb interactions

Treatment aims

• Normalise hormonal balance [14, 27] and restore normal menstrual cycle [14, 27, 48].

• Reduce and manage symptoms of elevated androgens [14, 27, 48].

• Support Gia’s ovarian function [14, 48] and maintain her fertility for the future [14, 26, 27].

• Help Gia lose weight and ensure she stays within normal BMI [26, 27, 48].

• Support Gia’s stress response [26, 30].

• Improve Gia’s diet and lifestyle [26, 27, 50].

• Improve insulin sensitivity [14, 26, 27, 50] and prevent potential progression to type 2 diabetes [15, 26, 27, 48].

• Support Gia’s antioxidant status [28] and cardiovascular health [26–29, 48, 58].

Lifestyle alterations/considerations

• Gia will benefit from regular exercise to help reduce her stress levels [32, 33] and improve her symptoms [26, 50]. Exercise should include both strength training and aerobic exercise [31], which will help reduce body fat and improve skeletal muscle mass and strength. This in turn will improve glucose control [26, 31].

• Gia will benefit from a weight-reduction program to bring her back into normal BMI range [26, 27, 50] but should avoid crash dieting and short-term weight loss [26].

• Gia may find relaxation therapies such as meditation, yoga, tai chi or autogenic (self-relaxation) training helpful to reduce her stress levels [26, 33].

• If Gia is a smoker she should quit [26].

Dietary suggestions

• Encourage Gia to follow a low GI and GL diet to improve glucose control [14–18, 35, 36] and improve her skin [34]. Dietary measures are essential for the management of polycystic ovarian syndrome [14, 26, 29, 35, 50].

• Encourage Gia to reduce consumption of saturated [14, 26, 35, 50] and trans fats [26] and increase consumption of monounsaturated fats [35, 36] and omega-3 fatty acid-rich foods. Omega-3 oils confer a range of benefits for general and reproductive health in women [38] and can improve glucose metabolism [37, 38].

• Encourage Gia to increase consumption of fibre from low GI sources [14, 26, 35, 36]. Soluble fibre can reduce postprandial glucose response and improve glycaemic control [16, 17, 36].

• Gia’s diet should be high in antioxidant-rich foods such as low GI whole grains, fruit, vegetables and legumes [14, 16–18, 26, 28].

• Encourage Gia to consume phyto-oestrogen-containing foods [14]. Lignans can increase levels of SHBG and reduce the biological activity of androgens [14, 41]; they also have a positive effect on ovulation and hormonal balance [14, 39].

• Gia should reduce or eliminate alcohol consumption [26] and significantly reduce her intake of caffeine [26].

• Encourage Gia to eat foods high in B-group vitamins, zinc, chromium, potassium, magnesium and vanadium. These are essential minerals for blood glucose regulation [14, 16–18].

• Encourage Gia to reduce her sodium intake and increase potassium intake while she is taking the herbal tonic or tablets [14, 19, 20].

• Encourage Gia to regularly include cinnamon in her diet to help with glucose control [40].

Physical treatment suggestions

• Gia is likely to benefit from a course of electro-acupuncture [41, 42]. Repeated electro-acupuncture can induce regular ovulation and reduce androgen levels in women with PCOS [41] and positively alter ovarian neuroendrocrine status [42].

• Gia may find massage therapy beneficial in helping reduce her stress levels [43, 44].

• Hydrotherapy: hot sitz baths or full baths are indicated for supressed menses [52, 53]. Taking a shallow cold sitz bath and placing the feet in a hot foot bath simultaneously eases pelvic congestion [52]. Alternatively have hot foot bath with a cold compress on the sacrum (if the feet are warm there is no need to heat the pelvic area – the cold will push blood back into the pelvic organs while the feet keep the core body temperature warm) [57].

• For acute period pain spray the pelvic area with a hot hand shower for two minutes, then alternate and spray with cold water for one minute (repeat three times) [54]. Place a hot compress/fomentation on the back during menstrual pain [54]. Apply a warm castor oil pack on the abdomen/pelvic area for menstrual cramps and constipation [54].

• For constipation place a hot compress on the abdomen, then cover in plastic with a hot water bottle/heating pad on top for 12 minutes, followed by cold mitten friction for 30 seconds (repeat process three times) [54].

• Weekly contrasting treatments between menses with a hot fomentation on the back and abdomen for 15 minutes, followed by 30-second cold mitten friction. Next, apply heat to the pelvic area and back for another 15 minutes, repeat the cold mitten friction with client in the side lying position (repeat alternating procedure three times) then follow with an abdominal massage [54].

• Constitutional hydrotherapy: lumbar wrap [53, 55].

• Use a facial steam treatment to clean the skin, followed by an oatmeal face pack [56]. Finish with a cold shower on the face [52].

TABLE 5.10 HERBAL FORMULA (1:2 LIQUID EXTRACTS)

Herb	Formula	Rationale
Paeonia Paeonia lactiflora	60 mL	Inhibits testosterone synthesis [14, 24]; enhances aromatase enzymes thereby promoting conversion of oestradiol from testosterone [14]; normalises ovarian function [14]; skeletal muscle relaxant [24]; combined with licorice, paeonia exerts a beneficial effect in PCOS [14, 19, 20, 24, 47] by improving LH:FSH ratio [14, 19, 24], reducing testosterone levels [14, 19, 20, 24, 47] and improving oestradiol to testosterone ratio [14, 24, 47]
Licorice Glycyrrhiza glabra	30 mL	Oestrogenic properties [14, 19]; adrenal tonic [19, 20]; antioxidant [19, 20]; beneficial in stress [19, 20]; mild laxative [19, 20]; beneficial in PCOS when combined with paeonia [14, 19, 20, 24, 47] – see above
Dandelion leaf Taraxacum officinale	40 mL	Diuretic [14, 20]; liver tonic [20]; rich source of potassium [14, 20]; beneficial to reduce the risk of hypokalaemia and hypertension from long-term use of licorice in herbal tonic or tablets [14]
Black cohosh Cimicifuga racemosa	20 mL	Reduces LH secretion [19, 20]; indicated for use in ovarian dysfunction [21] and PCOS [20]
Schisandra Schisandra chinensis	50 mL	Antioxidant [19, 23]; nervine tonic [23, 24]; adaptogenic [19, 23, 24]; hepatoprotective [19, 24]; improves mental, physical and sensory performance [24]; to support liver function [24, 48]
Supply:	200 mL	Dose: 5 mL 3 times daily

Chaste tree (Vitex agnus castus) 1000 mg tablet once daily

Beneficial for the treatment of latent hyperprolactinaemia [19, 20] and corpus luteum insufficiency [19, 20, 45]; beneficial in PMS [19, 20]; some women may experience a worsening of menstrual irregularity with chaste tree, so its use should be reviewed if this occurs with Gia [14]

TABLE 5.11 HERBAL TEA

Alternative to herbal liquid if Gia prefers a tea
HERB	FORMULA	RATIONALE
Paeonia root Paeonia lactiflora	2 parts	See above
Licorice root Glycyrrhiza glabra	1 part	See above
Black cohosh root Cimicifuga racemosa	1 part	See above
Hops Humulus lupulus	1 part	Mild sedative [23, 45]; oestrogenic action [19, 46]; anti-androgenic action [45, 46]; beneficial where stress and nervous tension accompanies PCOS [14]
Cinnamon bark powder Cinnamomum cassia	½ part	Antioxidant [19]; hypoglycaemic [40]; enhances insulin sensitivity [19]; traditionally used for female reproductive disorders [19]
Dandelion leaf Taraxacum officinale	1 part	See above

Infusion: 1 tsp per cup – 3–4 cups daily

TABLE 5.12 TABLET ALTERNATIVE TO HERBAL LIQUID: MAY IMPROVE COMPLIANCE

HERB	DOSE PER TABLET	RATIONALE
Paeonia Paeonia lactiflora	852 mg	See above
Licorice Glycyrrhiza glabra	847 mg	See above
Black cohosh Cimicifuga racemosa	300 mg	See above
Thuja Thuja occidentalis	250 mg	Traditionally used to support glandular function and to treat abnormal growths [49]

Dose: 2 tablets twice daily

TABLE 5.13 NUTRITIONAL SUPPLEMENTS

SUPPLEMENT AND DOSE	RATIONALE
High-potency practitioner-strength multivitamin, mineral and antioxidant supplement providing therapeutic levels of B-group vitaminsDosage as per manufacturer’s instructions	To ensure adequate levels of essential nutrient and antioxidants given Gia’s current poor dietary intake; to reduce oxidative stress [28]; B-group vitamins are required for glucose metabolism [22, 19]; increased need for B-group vitamins during times of excessive stress [22, 19]; to support Gia’s cardiovascular health [28, 51]; PCOS is associated with increased risk of cardiovascular disease [28, 58]
Supplement providing a daily dose of 200 µg chromium [16, 22] and 400 mg elemental magnesium [22]	Chromium enhances the effects of insulin [22, 25]; reduces skeletal muscle insulin resistance [16]; improves glucose control [16, 22, 25]; magnesium deficiency aggravates insulin resistance [16, 19, 25]; supplemental magnesium improves glucose tolerance [25] and insulin sensitivity [19, 22, 25]
Omega-3 fish oil 3000 mg daily [19]	Beneficial to improve Gia’s reproductive health [38] and to improve glucose metabolism [37, 38]