Post on 29-Mar-2015
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