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PCOS: An Integrative Approach Annemieke Austin MD Gordon Medical associates Unravelling Complex Chronic Illness 3471 Regional Parkway Santa Rosa, CA 95403.

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Presentation on theme: "PCOS: An Integrative Approach Annemieke Austin MD Gordon Medical associates Unravelling Complex Chronic Illness 3471 Regional Parkway Santa Rosa, CA 95403."— Presentation transcript:

1 PCOS: An Integrative Approach Annemieke Austin MD Gordon Medical associates Unravelling Complex Chronic Illness 3471 Regional Parkway Santa Rosa, CA (707)

2 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

3 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

4 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 the expert

5 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)

6 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

7 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

8 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

9 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

10 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)

11 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.

12 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

13 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

14 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

15 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.

16 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

17 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.

18 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 rice, esp rice bran

19 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

20 Testing Lipid panel Goals: triglycerides 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

21 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

22 Testing/Lab Results Most women with PCOS have a total testosterone > ng/dL Total Testosterone ng/dL or higher needs further workup LH/FSH >2 Prolactin: elevated in 10-20%

23 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 (most reliable)

24 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

25 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

26 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

27 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

28 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 mg per day -> good for scalp hair loss (Do not get pregnant) Vaniqa topically

29 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

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

31 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

32 Supplements for Insulin Resistance Magnesium – check RBC levels Dose: Mag Glycinate or taurate mg daily (at night) Chromium has been well studied in diabetes: Chromium picolinate mg daily

33 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: 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

34 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

35 And more supplements… For insulin resistance: Alpha Lipoic Acid, esp helpful in diabetes with nerve problems: mg/day Biotin: 2-5 mg Vitamin C mg/day (reduces glucose and improves IR) Omega-3s – 1-2 tablespoons Green Tea

36 Herbs Panax/American Ginseng before meals 1-3 grams 40 minutes before meals Bitter Melon mg three times/day Gymnema sylvestre: mg/day Fenugreek: 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)

37 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 Dec; 16(12): 12

38 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)

39 Environmental Cleanup Eat organic fruits and vegetables (www.ewg.org)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

40 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, mattress, furniture Consider an air filter

41 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

42 Beauty and Cosmetic Products Check the labels Go to www. organicconsumers.org/bodycare or skin deep website by the Environmental Working Group:

43 Detox Mobilization of pesticides, solvents, fat- loving chemicals: Caloric restriction, Sauna Therapy, Chelation Sauna is my favorite because it is very effective: up to minutes in hot dry sauna at 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.

44 Chelation EDTA/DMPS/DMSA Selenium, NAC, Alpha Lipoic Acid, Zinc, Modified Citrus Pectin

45 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

46 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 metabolism of estrogen

47 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

48 Other Detox support Castor Oil Packs High fiber: need regular bowel movements Probiotics/fermented foods Coffee enemas Drink ½ your body weight in ounces of filtered water each day

49 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

50 Contact Dr. Austin Annemieke Austin M.D. Gordon Medical associates Unravelling Complex Chronic Illness 3471 Regional Parkway (707) 575 – 5180


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