PCOS: An Integrative Approach - Gordon Medical Associates

PCOS: An Integrative Approach - Gordon Medical Associates

PCOS: An Integrative Approach Annemieke Austin MD Gordon Medical associates Unravelling Complex Chronic Illness 3471 Regional Parkway Santa Rosa, CA 95403 (707) 575-5180 [email protected] www.gordonmedical.com Martine: a patient example

Mid 30s, trying to get pregnant. Does not want to use fertility treatments because of the risk of having multiple births. Runs a Marathon every year, trains during the year 15 lbs overweight around the mid line Craves sugar, always snacking to prevent herself from getting dizzy Adult onset acne Chin hairs uses electrolysis Irregular Menstruation

Martine: a patient case Excess weight around the middle: insulin resistance Need for constant snacking: unstable blood sugar Excess Hair: excess testosterone With lifestyle changes and medication, she was able to have a healthy baby

History Hipocrates 400 BC described 2 cases of women who developed excess hair growth and whose menses ceased. Drs Irvin Stein and Michael Leventhal coined the term polycystic ovary in 1935 Dr. Futterweit published the textbook Polycystic Ovarian Disease in 1984, considered

Epidemiology 6.5-8% of women overall (Up To Date) Approximately 6 million women in the United States 40% have a sister with PCOS, 35% have a mother with PCOS Very commonly associated or caused by insulin resistance (more on this later)

Symptoms/Clinical Manifestations Menstrual irregularity 75-80% Androgen Excess -> 50-90% have increased Testosterone/DHEAS -> hirsutism (excess hair growth), acne, male pattern balding Infertility due to anovulation Elevated Insulin Levels (even if not obese) Increased chance of early pregnancy loss

Symptoms/Clinical Manifestations Excess weight, sugar craving, inability to lose weight Abnormal blood lipids (cholesterol) Apple shaped Darkening of skin areas around the neck/skin folds Skin Tags Gray-white breast discharge

Sleep Apnea Pelvic Pain associated with cystic rupture Depression, anxiety, sleep disturbance Rapid weight change following cessation of BC Janets Story Health problems started at age 12 Irregular periods with prolonged bleeding for any years Depression, uncontrollable

hunger, irritability Weight problems/high cholesterol in her 20s Diagnosis of PCOS Rotterdam Criteria (need 2 out of 3) 1) Oligo and/or anovulation 2) Clinical and/or biochemical signs of hyperandrogenism 3) Polycystic ovaries (on

ultrasound) YOU CAN HAVE REGULAR PERIODS BUT STILL HAVE PCOS Diagnosis of Insulin Resistance Triglycerides of 150 or greater (100 or less is ideal) Triglyceride/HDL ratio > 3 HDL < 50 Blood Pressure > 130/85

Fasting Glucose of 110 125 Fasting insulin > 13 uIU/mL Fasting glucose/insulin ratio < 4/5 Low SHBG: likely due to excess insulin (not accurate if taking birth control) Pathophysiology/Causes #1: Hyperinsulinemia (Elevated Insulin Levels) Stimulates androgens (testosterone) production directly in the ovaries Suppresses SHBG (Sex Hormone Binding Globulin) production in

the liver, which increases Free testosterone and estrogen. Pathophysiology/Causes In PCOS, the egg follicle does not release the egg into the fallopian tube (no ovulation) This is likely due to a higher than normal testosterone level. When eggs are not released they produce cysts

Pathophysiology/Causes Defect in the hypothalamus -> increased LH pulse that stimulates the ovaries to increase secretion of male hormones (LH/FSH ratio increases) Defect in the ovarian production of testosterone due to abnormal enzyme action Genetic Causes Depakote/Valproate medication for epilepsy

Pathophysiology/Causes PCOS results in progesterone deficiency with excessive estrogen due to lack of ovulation Estrogen is like the gas pedal to the lining of the uterus, making periods heavier -> leads to Dysfunctional Uterine Bleeding Fat cells also have an enzyme that can increase production of estrogen

Environmental Links/Causes Bisphenol-A (BPA) has the most research linking it to PCOS and insulin resistance. BPA has estrogen like effects and can alter other hormones BPA levels have been found to be higher in women with PCOS, obese or not obese associated with higher testosterone levels as well BPA has been found in human tissue, blood,

urine, breast milk and fetal blood It is in plastic food/beverage containers, metal food cans and dental sealants. Environmental Links/Causes Phthalates affect menstrual cycles and ovulation. Phthalates are found in plastics esp in PVC products Vinyl upholstery, shower curtains,

raincoats, childrens toys DEHP a type of PVC/Phthalate can cause anovulation and disrupts hormones In men, it has been associated with obesity, insulin resistance Environmental Links/Causes Burden of heavy metals has been linked to PCOS Metals are known to disrupt the menstrual cycle/hormones/fertility

Cadmium, Mercury have been linked with hirsutism, hyperandrogenism, polycystic ovaries. Arsenic has been linked with insulin resistance and diabetes. Excess Bromide/Fluoride can be hormonal disrupters. Metals Cadmium: found in the soil, water, fertilizer Mercury: fish, pesticides, wood

preservatives, dental fillings, thermometers, fluorescent lights, skin care products, antiseptics, soil, forest fires Arsenic: chicken, other meats, fish (agricultural fertilizers), Hijiki seaweed, Shellfish, non organic Risks Increased risk of endometrial cancer (up to 5 times the risk) -> weight loss and birth control can

decrease the risk Increased risk of cardiovascular disease Increased risk of diabetes Increased risk of miscarriage Testing Lipid panel Goals: triglycerides <100, HDL > 60, LDL < 100 Glucose and Insulin tests: Fasting insulin > 13 uIU/mL Fasting glucose/insulin ratio < 4/5

Low SHBG: likely due to excess insulin (not accurate if taking birth control) Hormones: estrogen/progesterone/testosterone (free & Total), Prolactin, LH, FSH, DHEAS, Androstenedione, Thyroid panel, 17 alpha Hydroxyprogesterone Testing If not menstruating: always test thyroid/adrenals (including hyperplasia)/pituitary hormones

Chronic stress/ steroids/extreme exercise/anorexia can also cause problems. Thyroid disorders, Anemia and low Estrogen can cause hair thinning Testing/Lab Results Most women with PCOS have a total testosterone > 60-70 ng/dL Total Testosterone 70 -150 ng/dL or higher needs further workup

LH/FSH >2 Prolactin: elevated in 10-20% Testing for Ovulation Home kits: tests for LH surge -> ovulation 24 hours later Basal body temperature: increases by 0.3 to 0.5 F after ovulation -> take at the same time each morning Progesterone blood level on days 21-23 (most reliable)

Examination Centrally distributed obesity Hip/waist ratio of > 0.8 Look for male pattern hair loss/thinning/texture of the hair Acne Abnormal hair growth Skin changes Pelvic ultrasound day 4-8 cysts/uterine lining

Treatment #1 is diet and exercise Low glycemic/Low Insulin-emic Diet High Fiber Healthy Fats including raw nuts No fake sugars No processed foods or flours Milk has lots of sugar and carbohydrates Exercise

Conventional Treatment Metformin: for insulin resistance, regulates menstrual cycle, reduces testosterone levels, weight loss Before starting metformin for fertility: ultrasound and progesterone treatment (Prometrium 200 mg every night for 7-10 days) If not ovulating after 2-3 months, will add Clomiphene (together 80% chance of ovulating) Stop Metformin once you become pregnant Metformin crosses the placental barrier but studies show no harm

Conventional Treatment: Acne Mild acne: birth control (suppresses testosterone) Moderate severe acne: Spironolactone 50 75 mg twice a day -> takes 3-4 months (Take with birth control) Triple therapy: birth control/spironolactone and metformin Avoid excess washing and scrubbing Dont squeeze pimples

Use non-comedogenic products Conventional Treatment: Unwanted Hair Birth control (10% notice improvement) Spironolactone up to 200 mg per day for at least 6 months Metformin maybe but takes 9-12 months for visible improvement 5 alpha reductase inhibitors (not approved for use in women) Finasteride 2.5-7.5 mg per day -> good for scalp

hair loss (Do not get pregnant) Vaniqa topically Hair Loss Male Pattern Baldness Treat right away as hair often does not grow back Spironolactone is most commonly used first line Can add birth control and finasteride or dutasteride Rogaine modestly useful

Treatment - integrative Again: weight loss, even modest amounts (7-10%) can induce ovulation Stress management (to decrease cortisol levels) Diet therapy as discussed previously Foods that improve insulin Brassica

Family broccoli, cabbage, brussels sprouts, cauliflower Green leafy vegetabels Legumes Fiber: oat bran, guar gum, psyllium lower post meal insulin Healthy fats: flaxseed, walnuts, soy, fish, algae Supplements for Insulin Resistance Magnesium

check RBC levels Dose: Mag Glycinate or taurate 200-800 mg daily (at night) Chromium has been well studied in diabetes: Chromium picolinate 200-1000 mg daily Supplements D-Chiro-Inositol: 1200 mg/day Increases action of insulin, improved ovulatory function and decreased

androgens, blood pressure & triglycerides in women with PCOS (NEJM 1999:340:1314-1320 Nestler JE) It is found in buckwheat, not commercially available except for the precursor D-Pinitol by Vital Nutrients Cheaper alternative: inositol 500 mg twice per day Other supplements Vanadium, L- Arginine, Berberine Berberine has been compared to

metformin in studies in diabetes using 500 mg three times a day Compared with Metformin, berberine exhibited and identical effect in the regulation of glucose metabolism. In the regulation of lipid metabolism, berberine is better than Metformin Efficacy of berberine in patients with type 2 DM Metabolism, 2008:57 (5): 712-7 And more supplements For insulin resistance:

Alpha Lipoic Acid, esp helpful in diabetes with nerve problems: 600-1800 mg/day Biotin: 2-5 mg Vitamin C 1000-2000 mg/day (reduces glucose and improves IR) Omega-3s 1-2 tablespoons Green Tea Herbs Panax/American Ginseng before meals 13 grams 40 minutes before meals

Bitter Melon 100-200 mg three times/day Gymnema sylvestre: 400-600 mg/day Fenugreek: 10-100 gm/day powder away from other meds Garlic Saw Palmetto for male pattern balding 450 mg twice per day for 3 months (do not get pregnant) Maitake Mushroom Induces ovulation in patients with PCOS 80 patients: maitake or clomid for 12

weeks to induce ovulation After 3 cycles, maitake group ovulated 76.9% and the clomid group ovulated 93.5% Each tab had 18 mg of maitake extract and 250 mg of dried maitake mushroom, 3 tabs three times a day for 3 months J Altern Complement Med. 2010 Dec; 16(12): 12 Vitamin D and Calcium Vitmain D deficiency among 13

women with PCOS Given calcium and vitamin D supplementation (1500mg Ca/day + 50,000 D2/week) Normalized menstruation and fertility in 9/9 woen with PCOS in 3 months Thys-Jacobs. Steroids 1999;64(6) Environmental Cleanup Eat organic fruits and vegetables ( www.ewg.org)

Wild fish, not farmed, and low in mercury Avoid food stored in plastic Cans free of BPA: Eden/Vital Choice, some Trader Joes Organic Meat and Diary to avoid hormones, pesticides and PCBs Cook at low temps Avoid plastic water bottles : avoid numbers: 1,3,6,7. Do not wrap food in plastic Water/Air Water

filtration is important to get rid of contaminants like pesticides, herbicides, formaldehyde, detergents, pthalates, PCBs, Chlorination, lead, copper, PVC Indoor air: formaldehyde, phthalates from carpet, cleaning products, vinyl flooring, dry cleaning, floor polish, carpet shampoo, air fresheners, Plants to filter the air Boston

Ferns Areca palms Lady palms Bamboo Palm (solvents) Rubber plants (formaldehyde) English Ivy Dwarf Date Palms Peace Lillies Golden Pothos Dracaena Janet Craig Beauty and Cosmetic Products

Check the labels Go to www. organicconsumers.org/bodycare or skin deep website by the Environmental Working Group: www.cosmeticdatabase.com www.safecosmetics.org Detox Mobilization of pesticides, solvents, fatloving chemicals: Caloric restriction,

Sauna Therapy, Chelation Sauna is my favorite because it is very effective: up to 10-15 minutes in hot dry sauna at 120-140 degrees followed by 30 second cold shower, repeat 3-4 times as tolerated Infared may be better tolerated, increase to 30 minutes in the sauna x 2. Chelation EDTA/DMPS/DMSA Selenium, NAC, Alpha Lipoic Acid,

Zinc, Modified Citrus Pectin Liver Detox Cruciferous vegetables, beets, green tea, pomegranate, flax seed, artichoke, psyllium Detox supplements: phase 1 and phase 2 liver detox support Herbs: burdock, dandelion, milk thistle, beet root, artichoke Estrogen Detox Support

DIM, Calcium D Glucarate, NAC, ALA, methylB12, Methyl Folate DIM is found in cruciferous vegetables Methylation (B12/folate) Calcium D Glucarate (cruciferous veggies) allows body to excrete excess estrogen DIM: metabolite of I3C, improves Hydrotherapy

Alternating hot and cold shower, 3 minutes hot, 30 seconds cold, repeat 3 times Epson Salt Bath: 10 minutes follow by 1 minute cold shower Colon Hydrotherapy Other Detox support Castor Oil Packs High fiber: need regular bowel

movements Probiotics/fermented foods Coffee enemas Drink your body weight in ounces of filtered water each day Summary Clean up your diet/air/water Get rid of chemicals in the home Sauna Nutrition most important A few carefully chosen

supplements Exercise Stress Reduction Detox Contact Dr. Austin Annemieke Austin M.D. Gordon Medical associates Unravelling Complex Chronic Illness 3471 Regional Parkway (707) 575 5180 [email protected] www.gordonmedical.com

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