When a woman is not menstruating or ovulating, an insufficient amount of the hormone progesterone is produced. This hormonal imbalance can lead to an overgrowth of the lining of the uterus (endometrial hyperplasia) and can increase a woman's risk of developing endometrial cancer. Women with PCOS who do ovulate and become pregnant tend to have an increased risk of complications such as miscarriage.
Key terms for the first search included: title or abstract CONTAINS ‘herbal medicine’ OR ‘herbal extract*’ OR ‘phytotherapy’ OR ‘botanical’ AND title or abstract CONTAINS ‘androgen*’ OR ‘oestrogen*’OR ‘follicle stimulating hormone’ OR ‘luteinising hormone’ OR ‘prolactin’ OR ‘insulin’ OR ‘glucose’ OR ‘polycystic ‘ovar*’. Search terms for the second search included the following key words in the title or abstract, CONTAINS; ‘menstrual irregularity’ OR ‘oligomenorrhoea’ OR ‘amenorrhoea’ OR ‘hyperandrogenism’ OR ‘hirsutism’ OR ‘acne’, OR ‘polycystic ovary syndrome’ OR ‘PCOS’ OR ‘polycystic ovar*’ OR ‘oligo-ovulation’ OR ‘anovulation’ OR ‘fertility’ OR ‘infertility’ OR ‘pregnancy’ AND ten herbal medicines identified from the laboratory search; ‘Cimicifuga racemosa’ OR ‘Cinnamomum cassia’ OR ‘Curcuma longa’ OR ‘Glycyrrhiza ‘ OR Matricaria chamomilla OR ‘Mentha piperita’ OR ‘Paeonia lactiflora’ OR ‘Silybum marianum’ OR ‘Tribulus terrestris’ OR ‘Vitex agnus-castus’. Truncation was used to capture plural key words and synonyms, and acronyms were used for some hormones (FSH and LH).
The prevalence of insulin resistance in women with PCOS, as measured by impaired glucose tolerance, is substantially higher than expected compared with age-and weight-matched populations of women without PCOS.45 Although insulin resistance alone is a laboratory (not clinical) aberration, it can lead to diabetes, and it may be associated with the metabolic syndrome, thus leading to increased cardiovascular risk.2 As with diabetes, optimal treatment of PCOS requires lifestyle modifications (e.g., diet, exercise) in addition to appropriate medications.
Our second search for clinical trials was performed without language restriction and included randomised controlled trials, non-randomised, open label and single arm clinical trials. We included clinical studies investigating commercially available herbal extracts and investigations that compared the effectiveness of herbal medicine with pharmaceuticals. We excluded clinical studies investigating herbal medicines with unrelated outcomes (including pre-menstrual syndrome, endometriosis and mastalgia) and clinical studies examining the effectiveness of complex herbal formulas for PCOS and associated oligo/amenorrhoea and hyperandrogenism, without demonstration of a mechanism of effect for the whole complex formula. We compared data from laboratory and animal studies with the outcomes of clinical trials. Clinical studies were assessed for risks of bias at study and outcome levels with risks summarised, tabulated (Tables 1 and and2)2) and presented in contextual narrative.
Polycystic ovary syndrome (PCOS) can be a daunting diagnosis to receive. The National Polycystic Ovary Syndrome Association defines the condition as a “genetic, hormonal, metabolic, and reproductive disorder that affects women.” (1) One in 10 women have it (about half don’t know it), and the complications can include infertility, obesity, and mood disorders.
Some have tried to utilize ultrasound to detect IR. Of note, normoglycemic women often have the phenotypic criteria for polycystic ovaries on ultrasound, consistent with other data in young adolescents showing that polycystic ovaries by ultrasound appearance often does not correlate with either anovulatory menstrual cycles or metabolic abnormalities. Therefore ultrasound is too non-specific to use with any reliability in measuring IR.
Irregular uterine bleeding from PCOS is usually due to lack of ovulation. Under this circumstance, the fragile lining of the uterus (endometrium) becomes thickened from excess estrogen and is not corrected by the monthly production of progesterone from the ovary that normally follows ovulation. Consequently, oral contraceptives (which contain progesterone-like substances), progesterone alone, or possibly a progestin-releasing intrauterine device, can be used to reverse the actions of estrogen on the uterine lining. Rarely, abnormal uterine bleeding after childbearing that does not respond to medical therapy may require surgical therapy.
One laboratory study and two clinical investigations provided evidence for the two herb combination, Glycyrrhiza uralensis and Paeonia lactiflora[53, 58, 59] (Table 1). An animal study found significant reductions in free and total testosterone following exposure to the combination  (Table 1). These findings were supported in two open label clinical trials including women with PCOS (n = 34)  and women with hyperandrogenism (n = 8) . Both trials examined the effects on androgens for the aqueous extract TJ-68 (equal parts Glycyrrhiza uralensis and Paeonia lactiflora), 75 grams per day for 24 weeks and 5–10 grams per day for 2–8 weeks respectively. In the trial including women with PCOS, mean serum testosterone was significantly reduced from 137.1 ng/dL (±27.6) to 85.3 ng/dL (±38), p < 0.001 at four weeks of treatment . Similar effects were observed in the women with oligomenorrhoea and hyperandrogenism which showed serum testosterone reduced from 50-160 ng/dL prior to treatment to less than 50 ng/dL . However statistical significance was not reached due to the small sample size despite positive outcomes in seven out of eight participants (Table 1).
Metformin. Metformin is often used to treat type 2 diabetes and may help some women with PCOS symptoms. It is not approved by the FDA to treat PCOS symptoms. Metformin improves insulin's ability to lower your blood sugar and can lower both insulin and androgen levels. After a few months of use, metformin may help restart ovulation, but it usually has little effect on acne and extra hair on the face or body. Recent research shows that metformin may have other positive effects, including lowering body mass and improving cholesterol levels.