Polycystic Ovarian Syndrome or PCOS is a common endocrine disorder affecting about 10% of women of reproductive age. Although it is very common, it often goes undiagnosed for many years as the symptoms may vary for each affected woman.
So what exactly is PCOS? PCOS was first described in 1935 by Doctors Stein and Leventhal in women who were obese, had irregular menstrual cycles, ovarian cysts, acne and excess hair growth (hirsutism). PCOS was considered a hormonal imbalance where women had excess androgens (male hormones like testosterone) as the underlying cause of their symptoms. Although these are considered "classic" symptoms of PCOS, not all women experience all of these symptoms. It is now known that PCOS is a much more complex syndrome which is not only an endocrine (hormonal) disorder but a metabolic disorder as well. Many women with PCOS also have Insulin Resistance as a driving factor of symptomatology.
So what are the symptoms of PCOS? Symptoms of PCOS include infertility, irregular periods, acne, weight gain, facial hair, and thinning of hair or hair loss. Women with PCOS also have higher rates of depression and anxiety which may be related to the underlying inflammation associated with PCOS. There is also an increased rate of eating disorders in patients with PCOS, especially Binge Eating Disorder. Left untreated, women with PCOS also have higher rates of diabetes, heart disease, endometrial cancer and stroke.
So what causes PCOS? We know that genetics plays a role in the development of PCOS but the causes are multifactorial. Your genes are not your destiny! Your genetic predispositions may be improved or harmed by environmental factors and exposures including lifestyle factors like stress. We know that 50-70% of women with PCOS show measurable insulin resistance. Insulin stimulates secretion of testosterone in the ovary which leads to elevated levels of circulating testosterone which accounts for symptoms like acne, hirsutism and male pattern hair loss. We also know that gut dysbiosis (imbalance of gut bacteria) as well as the function of our mitochondria (energy centers of our cells) may contribute to the development of PCOS. How your body processes carbohydrates, fats and proteins may be impaired if your mitochondrial function is impaired.
How is PCOS diagnosed? PCOS is diagnosed clinically- meaning that women may experience some or all of the classical symptoms discussed after other conditions have been ruled out. Blood testing and ultrasounds of the ovaries may help to confirm PCOS but lack of abnormalities on hormonal testing or lack of small ovarian cysts does not mean that you do not have the condition. Test results may be variable according to the timing of when they are taken.
I think I may have PCOS or I have been diagnosed with PCOS. What should I do? It is important to be evaluated by a physician knowledgeable in the diagnosis and treatment of PCOS as appropriate intervention is necessary to avoid long term health consequences. Some actionable steps are:
1) Balance your Blood Sugar- It is important to keep your blood sugar in check as we know that many women with PCOS have measurable insulin resistance. Your physician may recommend medications such as Metformin to lower insulin resistance and stabilize your blood sugar. However, it is equally important to maintain healthy eating habits that will keep blood sugar balanced during the day. This can be accomplished by eating regular meals throughout the day which contain protein, healthy fats and vegetables. Limit simple carbohydrates and avoid sugar and processed foods. The more plants and color in the diet the better! There are well studied supplements and herbs that help to balance your blood sugar as well. Work with a physician knowledgeable in how to incorporate these into your therapeutic plan.
2) Nourish your Adrenal Glands- Let's face it. Most of us are under some degree of chronic stress. The high levels of cortisol secreted by the adrenal glands in response to stress increases our blood sugar which leads to insulin resistance. We can help to support our adrenal glands and invoke a relaxation response through meditation and getting adequate sleep. While exercise is great, over-training may actually illicit a stress response in the body and increase inflammation. Speak with your doctor to see if your current exercise regimen is serving you well.
3) Balance your Hormones and Support Hormonal Detoxification - One of the mainstays to balance circulating testosterone levels is the use of oral contraceptive pills. They work to lower testosterone levels by increasing binding globulins that help to bind up the excess circulating testosterone. They also allow women to achieve regular menstrual cycles. While it is standard practice to use oral contraceptive pills, they are not without side effects. There are also well studies supplements and herbs that may be helpful as part of your therapeutic plan to help with lowering your testosterone levels. We should also be mindful to reduce our environmental exposures to chemicals that act as hormone disruptors. From the food we eat, to our household products, to our beauty products, to our food packaging, it is important to be mindful of the chemicals that we are putting both on and in our bodies.
PCOS is a complex syndrome with many root causes and potential interventions. Speak with your doctor to see if your symptomatology may be due to PCOS and what interventions may be right for you.
We are now several weeks into Stay-At-Home orders in response to the COVID-19 Pandemic. As the days and weeks go by, we are learning more and more about the SARS- CoV-2 virus ( the virus causing what we refer to as COVID-19), its symptoms, treatment possibilities and testing. Lets take a look at what we know about testing.
There are two types of testing available at this time for SARS-CoV-2 testing:
Antibody tests or serologic tests are used to determine which people have been exposed to the virus at some point in the past.
These tests are performed with serum or plasma and require a blood draw. Antibody tests are not used to diagnose patients, but rather give information as to whether or not someone may have been exposed to SARS-CoV-2 in the past. Many people are questioning if the "flu-like illness" they experienced last month may have actually been SARS-CoV-2. This test gives us the ability to determine if that was indeed a possibility. Many people never develop symptoms but still may develop antibody responses. The timing of antibody development, ( IgA, IgM , IgG) varies among individuals, but it is likely best to obtain antibody tests about 14 days on average after symptoms begin. IgA and IgM rise initially followed by IgG, which is typically the antibody which confers immunity to some degree. In the case of SARS-CoV-2, we are unsure at this point if antibody testing is able to tell us if someone is immune to reinfection. It is important to keep in mind that when choosing a lab to do antibody testing , it is important to know the lab's ability to provide sensitivity and specificity data. As of the end of April 2020, there are only a handful of labs that have been granted Emergency Use Authorization by the FDA to conduct SARS-Cov-2 antibody testing.
The understanding of SARS-CoV-2 is continually evolving as more is learned about the virus and individual's response to infection. It is important to discuss both diagnostic and antibody test options with your physician in order to obtain the safest, most accurate and appropriate testing for your needs.
In the United States, we are currently on the trajectory to double COVID-19 cases every 2-5 days. At this rate, there is a significant potential that we will soon overwhelm our healthcare system, placing us in similar situations as Italy and China and leaving the most vulnerable at even higher risk.
We have the power to slow this trajectory and " flatten the curve" by:
1) Practicing " social distancing". Social distancing is the practice of reducing close contact between people to slow the spread of infections or diseases. While it is true that 80% or more of people with COVID-19 will have mild illness, the concern is that those who have mild symptoms or who are asymptomatic may actually be the biggest vectors in unwittingly spreading novel coronavirus to the most vulnerable populations ( the elderly and those with underlying health conditions). Maintain physical distance but stay connected via phone or video chats.
2) Keep our immune system robust and supported :
It is estimated that 20 million women and 10 million men in the United States will have an Eating Disorder at some point in their lives. Eating Disorders are serious but treatable mental health conditions that may affect anyone of any age, sex, gender, ethnicity, race or socioeconomic group.
So what are the different types of Eating Disorders and what are the different types of treatment available? According to the DSM-5:
Anorexia Nervosa is defined as:
Bulimia Nervosa is defined as:
misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise.
3. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for
4. Self- evaluation is unduly influenced by body shape and weight.
5. The disturbance does not occur exclusively during episodes of anorexia nervosa,
Binge Eating Disorder is defined as:
4. Absence of regular compensatory behaviors (such as purging).
Avoidant Restrictive Food Intake Disorder (ARFID) is defined as:
3. The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder.
While there are some people whose symptoms may fit neatly into one of these diagnostic criteria, there are others that may experience symptomatology encompassing multiple disorders or may not represent a full syndrome eating disorder. These people may fall into the diagnostic criteria known as Other Specialized Feeding or Eating Disorder and consequences of the disorder are no less serious than Anorexia, Bulimia, Binge Eating Disorder of ARFID.
Regardless of the diagnosis, early and appropriate intervention is necessary and is associated with the best outcomes. Eating disorders carry the highest mortality rate of any mental health disorder. The high mortality rate may be due to either medical complications or suicide. Well coordinated care is essential for people with eating disorders as eating disorders are very complicated medically as well as psychologically and need to be monitored by professionals who understand and are well versed in how to manage the potential risks. There are various treatment levels or settings of care that are available to conduct treatment. The level of care may be largely based on the patient's medical stability or past history of treatment. Levels of care may include ( from least restrictive to most intensive):
Regardless of the treatment level, multiple professionals are typically involved in patient care with each having a distinct role on the team. Adolescent Medicine physicians (Board-certified medical doctors who specialize in teens and young adults) have obtained special training in medical management of patients with eating disorders. Other vital members of the treatment team include therapists and nutritionists with expertise in eating disorders. It is imperative that all members of the treatment team maintain open communication and collaborate so that patients can be supported adequately in the recovery process.
Eating Disorders are complex both medically and psychologically. During this week of awareness and every day, let's support those who are struggling by letting them know that help is available . You are not alone. Reach out for help. Recovery is possible!
Did you know that over 20 million Americans have some form of thyroid dysfunction? According to the American Thyroid Association, up to 60% of those with thyroid disease are unaware that they have the condition. Women are five to eight times more likely than men to have thyroid disease and one in eight women will develop a thyroid disorder during their lifetime.
So what exactly is the thyroid and why might its function go awry? The thyroid is a butterfly shaped gland that sits in the middle of your neck. Although this gland is relatively small in size, it produces hormones (triiodothyronine and thyroxine) that influence every cell and organ in the body. Hypothyroidism is a condition where the thyroid produces too little hormone while hyperthyroidism is a condition where the thyroid produces too much thyroid hormone. Symptoms of hypothyroidism include weight gain, brain fog, constipation, fatigue and mood disorders to name a few. Symptoms of hyperthyroidism include nervousness, unexplained weight loss, palpitations and heat intolerance.
In fact 90% of cases of hypothyroidism are actually autoimmune in nature. What is important to note is that autoimmune hypothyroidism- called Hashimoto's thyroiditis- is not purely a problem with the thyroid gland. It is actually a problem of the immune system. The immune system is attacking the thyroid gland causing it to under produce its hormones which in turn slows down all of the body's metabolic processes. But why does this happen?
We know that autoimmune thyroiditis has genetic underpinnings. But as we now, our genes are not necessarily our destiny. As I tell my patients quite often, our genes may load the proverbial gun, but our environment pulls the trigger. Let's take a closer look...
We know through the pioneering work of Dr. Alessio Fasano, Chief of Pediatric Gastroenterology and Nutrition at Mass General Hospital, that in order for an autoimmune disease to take hold, we need three things: 1) a genetic predisposition 2) a trigger from our environment and 3) intestinal permeability or a " leaky gut". When the tight junctions in our intestinal wall become loosened ( due to a multitude of reasons including inflammatory foods, stress, medications, environmental toxins and infections to name a few) things like undigested food particles, microbes and toxins enter our bloodstream and set off an inflammatory or immune response to deal with the invaders. Unfortunately our own tissues may get caught in the crossfire and if the genetic predisposition is there, an autoimmune disease may take hold.
So once this train has left the station, what can we do to quell the autoimmune process? Here are some actionable tips:
1) Heal your gut - 80% of your entire immune system is located in your digestive tract. To help halt and reverse the autoimmune process, we should work on restoring healthy gut function by removing inflammatory foods and infections, replacing enzymes needed for healthy digestion, reinocculating our gut with healthy bacteria from probiotics and probiotic rich foods and repairing the gut lining with nutrients.
2) Optimize your diet - eat a diet rich in whole, phytonutrient rich foods and avoid processed, inflammatory foods.
3) Eliminate toxins in your environment - by filtering your water, avoiding chemical laden body products and household cleaners.
4) Heal infections - a number of infections have been associated with autoimmune disease including Epstein Barr Virus and Yersinia Enterocolitica to name a few. Work with your doctor to see if you may have an infection that may be contributing to your autoimmune process.
5) Relieve your stress- find what works for you. Proper thyroid and immune function depends on healthy adrenal glands. Send your body a signal of safety and decrease stress hormone production through practicing yoga, meditation, journaling or perhaps going on nature walks.
The interplay between the endocrine and immune system is a complicated web. It can take some time to figure out your own personal autoimmune triggers that led to the diagnosis of Hashimoto's thyroiditis. Figuring out your root causes and triggers, finding the right supplementation and medications may take some time. Work closely with your physician to dig deep to achieve your optimal wellness!
Ahhh The Matrix... Many of us know the late 90's blockbuster movie. Red pill...Blue pill... Which one? The term "The Matrix" however, has a much different meaning for physicians who practice Functional Medicine. You may have heard of the term Functional Medicine, but what exactly is it and what is the Matrix as it pertains to health and wellness?
Functional Medicine is a science based approach to health that focuses on identifying and addressing the root cause of disease rather than just treating the symptoms. One condition or diagnosis may have many causes and one cause may actually produce many conditions. For example, if we look at the diagnosis of depression, we see in the image below that depression may have many causes. Likewise, a cause, such as inflammation, may lead to a number of diagnoses including depression. One person's cause of depression may be different from another person's. So perhaps the reason why your SSRI is not helping to resolve your depression is because your unique cause is not being addressed.
The beauty of the functional medicine approach is that it takes the focus off of the name of the illness and instead allows the physician and patient to work together to find the underlying cause unique to each person in a truly personalized approach. Whether the diagnosis is anxiety, ADHD, acne, eczema, autoimmune disease, irritable bowel syndrome, migraine... it is important to look beneath that name and see what got you to the point at which you were given your diagnosis. Naming the issue is just the beginning! Getting to "the why" is where the magic happens. It is only then that we can achieve long term sustainable health without perpetually suppressing symptoms.
The Functional Medicine Matrix helps physicians to organize patient information and guides them where to begin treatment. The matrix shows how diverse symptoms may be linked and helps to determine which systems need the most support first. It allows for looking more deeply into where the imbalance for each individual may lie and where precipitating factors, triggers, and perpetuating factors keep the disease process going on. Looking at the "Functional Medicine Tree" is a great way to illustrate this process.
Rather than focusing on the branches and leaves at the very top of the tree which represents symptoms and diagnosis, the functional medicine model begins at the roots. The traditional medical model tends to focus in the branches and leaves. In order to keep a tree healthy, you need to support its very foundation- the roots and the soil. If a tree is not healthy, the first place you should look is at these same foundational elements. During the patient interview, these foundational issues ( sleep, exercise, nutrition, stress, relationships, genetics, etc) are examined and addressed along with predisposing factors ( antecedents), events ( triggers), and ongoing physiological processes ( mediators). These influences may then result in the core imbalances that we see in the trunk. The symptoms that patients experience are due to the body's response to these functional core imbalances. Symptoms are in essence the body's attempt to reestablish balance and restore health. A comprehensive medical history and physical examination conducted through the lens of this matrix along with diagnostic laboratory testing allows the physician to ask two very important questions which guide therapy:
1) Does this person need to be rid of something such as allergens,toxins, infections,stress or poor diet?
2) Does this person have an unmet need that must be filled for optimal health and function such as vitamins, minerals, nutrients, protein, fat, carbohydrates, hormones, sleep, relaxation, community, purpose?
The aim is to answer these complex questions and work in therapeutic partnership with the patient and perhaps their family to remove the impediments to health and replace the unmet needs to restore the patient to optimal function. Not only does this approach help to tease through causes of symptoms and disease, it is also a very powerful tool for preventative medicine and overall health and well-being. In fact, In October 2019, a study was published in JAMA which demonstrated that the Functional Medicine model of care achieved better health related quality of life scores than standard medical care in a traditional family health center.
The conventional model of healthcare divides body systems and medical specialties into silos such as endocrinology, neurology, dermatology and gastroenterology. The human body, however, is wonderfully connected in an infinite web. If you would like to climb down from the canopy of leaves, dig into the soil and get down to the roots, perhaps the Functional Medicine approach is for you. Take a walk through the Matrix. You may be surprised with what you find.