Transcript PCOS: An Integrative Approach

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 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 line
 Craves sugar, always snacking to prevent
herself from getting dizzy
 Adult onset acne
 Chin hairs – uses electrolysis
 Irregular Menstruation
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Martine: a patient case
Excess weight around the middle: insulin
resistance
 Need for constant snacking: unstable
blood sugar
 Excess Hair: excess testosterone
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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 “the expert”
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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)
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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
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Symptoms/Clinical Manifestations
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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
Janet’s 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
20’s
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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)
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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)
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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”
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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
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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
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Environmental Links/Causes
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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, children’s toys
 DEHP a type of PVC/Phthalate can cause
anovulation and disrupts hormones
 In men, it has been associated with
obesity, insulin resistance
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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.
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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
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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
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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
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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
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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%
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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)
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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
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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
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Conventional Treatment
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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
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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
Don’t 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
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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
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Treatment - integrative
Again: weight loss, even modest amounts
(7-10%) can induce ovulation
 Stress management (to decrease cortisol
levels)
 Diet therapy as discussed previously
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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
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Supplements for Insulin Resistance
Magnesium – check RBC levels
Dose: Mag Glycinate or taurate 200-800 mg
daily (at night)
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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
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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
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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-3’s – 1-2 tablespoons
 Green Tea
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Herbs
Panax/American Ginseng before meals 1-3
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)
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Maitake Mushroom
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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)
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Environmental Cleanup
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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 PCB’s
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, 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
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Plants to filter the air
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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
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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.
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Chelation
EDTA/DMPS/DMSA
 Selenium, NAC, Alpha Lipoic Acid, Zinc,
Modified Citrus Pectin
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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
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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
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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
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Other Detox support
Castor Oil Packs
 High fiber: need regular bowel
movements
 Probiotics/fermented foods
 Coffee enema’s
 Drink ½ your body weight in ounces of
filtered water each day
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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
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Contact Dr. Austin
AnnemiekeAustin M.D.
Gordon Medical associates
Unravelling Complex Chronic Illness
3471RegionalParkway
(707)575– 5180
[email protected]
www.gordonmedical.com