pcos: an integrative approach annemieke austin md gordon medical associates unravelling complex...

PCOS: An Integrative ApproachAnnemieke Austin MD

Gordon Medical associatesUnravelling Complex Chronic Illness

3471 Regional Parkway

Santa Rosa, CA 95403

(707) 575-5180

info@gordonmedical.com

www.gordonmedical.com

Martine: a patient exampleMid 30’s, 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 lineCraves sugar, always snacking to prevent

herself from getting dizzyAdult onset acneChin hairs – uses electrolysisIrregular Menstruation

Martine: a patient caseExcess weight around the middle:

insulin resistanceNeed for constant snacking:

unstable blood sugarExcess Hair: excess testosterone

With lifestyle changes and medication, she was able to have a healthy baby

HistoryHipocrates 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 “the expert”

Epidemiology6.5-8% of women overall (Up To

Date)Approximately 6 million women

in the United States40% have a sister with PCOS,

35% have a mother with PCOSVery commonly associated or

caused by insulin resistance (more on this later)

Symptoms/Clinical ManifestationsMenstrual irregularity 75-80%Androgen Excess -> 50-90% have

increased Testosterone/DHEAS -> hirsutism (excess hair growth), acne, male pattern balding

Infertility due to anovulationElevated Insulin Levels (even if not

obese)Increased chance of early pregnancy

loss

Symptoms/Clinical ManifestationsExcess weight, sugar craving, inability to lose

weightAbnormal blood lipids (cholesterol)Apple shapedDarkening of skin areas around the neck/skin

foldsSkin TagsGray-white breast dischargeSleep ApneaPelvic Pain associated with cystic ruptureDepression, anxiety, sleep disturbanceRapid weight change following cessation of BC

Janet’s StoryHealth problems started at age

12Irregular periods with prolonged

bleeding for any yearsDepression, uncontrollable

hunger, irritabilityWeight problems/high cholesterol

in her 20’s

Diagnosis of PCOSRotterdam Criteria (need 2 out of

3)1) Oligo and/or anovulation2) Clinical and/or biochemical

signs of hyperandrogenism3) Polycystic ovaries (on

ultrasound)

YOU CAN HAVE REGULAR PERIODS BUT STILL HAVE PCOS

Diagnosis of Insulin ResistanceTriglycerides of 150 or greater (100 or less is ideal)Triglyceride/HDL ratio > 3HDL < 50Blood Pressure > 130/85Fasting Glucose of 110 – 125Fasting insulin > 13 uIU/mLFasting glucose/insulin ratio < 4/5Low 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/CausesIn 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/CausesDefect 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 CausesDepakote/Valproate medication for

epilepsy

Pathophysiology/CausesPCOS 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/CausesBisphenol-A (BPA) has the most research

linking it to PCOS and insulin resistance. BPA has estrogen like effects and can alter

other hormonesBPA 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/CausesPhthalates affect menstrual cycles and

ovulation.Phthalates are found in plastics esp in

PVC productsVinyl upholstery, shower curtains,

raincoats, children’s toysDEHP a type of PVC/Phthalate can

cause anovulation and disrupts hormones

In men, it has been associated with obesity, insulin resistance

Environmental Links/CausesBurden of heavy metals has been linked

to PCOSMetals are known to disrupt the

menstrual cycle/hormones/fertilityCadmium, 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.

MetalsCadmium: found in the soil,

water, fertilizerMercury: 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 rice, esp rice bran

RisksIncreased 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 diabetesIncreased risk of miscarriage

TestingLipid panelGoals: triglycerides <100, HDL > 60, LDL < 100Glucose and Insulin tests:Fasting insulin > 13 uIU/mLFasting glucose/insulin ratio < 4/5Low 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

TestingIf 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 >2Prolactin: elevated in 10-20%

Testing for OvulationHome kits: tests for LH surge ->

ovulation 24 hours laterBasal 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)

ExaminationCentrally distributed obesityHip/waist ratio of > 0.8Look for male pattern hair

loss/thinning/texture of the hairAcneAbnormal hair growthSkin changesPelvic ultrasound day 4-8 –

cysts/uterine lining

Treatment#1 is diet and exerciseLow glycemic/Low Insulin-emic

DietHigh FiberHealthy Fats including raw nutsNo fake sugarsNo processed foods or floursMilk has lots of sugar and

carbohydrates Exercise

Conventional TreatmentMetformin: 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 pregnantMetformin crosses the placental barrier but

studies show no harm

Conventional Treatment: AcneMild 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 scrubbingDon’t squeeze pimplesUse non-comedogenic products

Conventional Treatment: Unwanted HairBirth control (10% notice improvement)Spironolactone up to 200 mg per day

for at least 6 monthsMetformin – maybe but takes 9-12

months for visible improvement5 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 BaldnessTreat right away – as hair often

does not grow backSpironolactone is most commonly

used first lineCan add birth control and

finasteride or dutasterideRogaine – modestly useful

Treatment - integrativeAgain: weight loss, even modest

amounts (7-10%) can induce ovulation

Stress management (to decrease cortisol levels)

Diet therapy as discussed previously

Foods that improve insulinBrassica Family – broccoli,

cabbage, brussels sprouts, cauliflower

Green leafy vegetabelsLegumesFiber: oat bran, guar gum,

psyllium lower post meal insulinHealthy fats: flaxseed, walnuts,

soy, fish, algae

Supplements for Insulin ResistanceMagnesium – check RBC levelsDose: Mag Glycinate or taurate 200-800 mg daily (at night)

Chromium has been well studied in diabetes: Chromium picolinate 200-1000 mg daily

SupplementsD-Chiro-Inositol: 1200 mg/dayIncreases 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 supplementsVanadium, L- Arginine, BerberineBerberine 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 mgVitamin C 1000-2000 mg/day

(reduces glucose and improves IR)

Omega-3’s – 1-2 tablespoonsGreen Tea

HerbsPanax/American Ginseng before meals

1-3 grams 40 minutes before mealsBitter Melon 100-200 mg three

times/dayGymnema sylvestre: 400-600 mg/dayFenugreek: 10-100 gm/day powder

away from other medsGarlicSaw Palmetto for male pattern balding

450 mg twice per day for 3 months (do not get pregnant)

Maitake MushroomInduces ovulation in patients with PCOS80 patients: maitake or clomid for 12

weeks to induce ovulationAfter 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 CalciumVitmain D deficiency among 13

women with PCOSGiven 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 CleanupEat organic fruits and vegetables (

www.ewg.org)Wild fish, not farmed, and low in mercuryAvoid food stored in plasticCans free of BPA: Eden/Vital Choice, some

Trader JoesOrganic Meat and Diary to avoid hormones,

pesticides and PCB’sCook at low tempsAvoid plastic water bottles : avoid numbers:

1,3,6,7.Do not wrap food in plastic

Water/AirWater filtration is important to

get rid of contaminants like pesticides, herbicides, formaldehyde, detergents, pthalates, PCB’s, Chlorination, lead, copper, PVC

Indoor air: formaldehyde, phthalates from carpet, cleaning products, vinyl flooring, dry cleaning, floor polish, carpet shampoo, air fresheners, mattress, furniture

Consider an air filter

Plants to filter the airBoston FernsAreca palmsLady palmsBamboo Palm (solvents)Rubber plants (formaldehyde)English IvyDwarf Date PalmsPeace LilliesGolden PothosDracaena Janet Craig

Beauty and Cosmetic ProductsCheck the labelsGo to www.

organicconsumers.org/bodycare or skin deep website by the

Environmental Working Group: www.cosmeticdatabase.com

www.safecosmetics.org

DetoxMobilization of pesticides, solvents,

fat-loving 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.

ChelationEDTA/DMPS/DMSASelenium, NAC, Alpha Lipoic Acid,

Zinc, Modified Citrus Pectin

Liver DetoxCruciferous 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 SupportDIM, 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 metabolism of estrogen

HydrotherapyAlternating 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 supportCastor Oil PacksHigh fiber: need regular bowel

movementsProbiotics/fermented foodsCoffee enema’sDrink ½ your body weight in

ounces of filtered water each day

SummaryClean up your diet/air/waterGet rid of chemicals in the homeSaunaNutrition most importantA few carefully chosen

supplementsExerciseStress ReductionDetox

Contact Dr. Austin

Annemieke Austin M.D.

Gordon Medical associatesUnravelling Complex Chronic Illness3471 Regional Parkway

(707) 575 – 5180

info@gordonmedical.com

www.gordonmedical.com