The PCOS PUZZLE An Integrative Approach to Putting the Pieces Together PRESENTED BY: ELIZABETH BOARD, MD FOUNDER OF ATLANTA FUNCTIONAL MEDICINE, INC. Agenda 2 uFunctional Medicine Principles uExamine the Pieces uPut them together uCase Examples Inspiration and some fun Functional Medicine Principles 3 u Biochemical individuality based on genetic and environmental uniqueness u Patient centered versus disease centered u Dynamic balance of internal and external factors u Web-like interconnections of physiological factors u Health as a positive vitality–not merely the absence of disease u Promotion of organ reserve–health span - www. functionalmedicine.org Your Personalized Treatment Plan 4 “God grant me the serenity to accept the things I cannot change, The courage to change the things I can, and the wisdom to know the difference.” Reinhold Niebuhr What Are the Puzzle Pieces? 5 Diet Intestinal Sleep Health We need a framework Voice Acupuncture to properly Supplements organize all of this Mind Body Activity information Medicine Detoxification Treatment Plan 6 u What do these ladies have in common? 7 They are all DIVAS ! Treatment Plan 8 D = DIET, DETOXIFICATION I = INTESTINAL HEALTH V = VEG OUT , VOICE A = ACTIVITY, ACUPUNCTURE S = SLEEP, SUPPLEMENTS Treatment Plan - DIVAS 9 u D = DIET u Elimination diet and REAL Food uEliminate: dairy, gluten, sugar, corn, fruit juice, processed foods, soy uFavor low glycemic load uEat unprocessed foods uIf it didn’t grow on a plant or walk, swim or fly it probably is NOT food. If a machine made it, feed it to a machine! Treatment Plan - DIVAS 10 u Elimination Diet Treatment Plan - DIVAS 11 u D = DIET u Anti-inflammatory diet and High Fiber u The Clean 15 and the Dirty Dozen www.ewg.org u “If it comes in a bag or a box, it’ll put you in a bag or a box”. u Eat Like a Queen, not a pauper. Nutrient Dense foods. Three different colors at each meal. u Use food as medicine when possible What you put in your body can alter your destiny! The Clean 15 The Dirty Dozen 12 u Avocado u Kiwi • Apple • Cherry u Papaya u Eggplant • Strawberries Tomatoes u Pineapple u Grapefruit • Grapes • Sweet Bell u Cabbage u Cantalope • Spinach Peppers u Sweet u Cauliflower • Cucumber • Celery • Potatoes • Peaches peas u Corn • Snap peas u Onions u Honeydew • Nectarines u Asparagus u Mangoes (imported) www.ewg.org DIVAS – Diet 13 Types of Hunger Treatment Plan – DIVAS- 14 Detoxification u First Step is to limit exposure v Avoid Bisphenol A v Check your makeup: www.ewg.org/skindeep v Avoid heating plastics v Avoid Propyl Paraben (in tortillas, muffins, diet cakes, trail mix and dyes) v Avoid Butylated Hydroxyanisole or BHA in chips, preserved fats and processed meat v Avoid Pesticides www.ewg.org Treatment Plan - DIVAS 15 u I = INTESTINAL HEALTH u Healthy gut? Suspect if any gi sypmtoms. u “Gut Restoration” & Prebiotics and Probiotics u Hormone reabsorption risk u Higher prevalence of IBS compared to controls u Herbal accelerators: grape skin, Brassica family, garlic, rosemary these flavonoids induce phase II (the rate limiting step) u Increase hydration to support kidneys Take the garbage out everyday! Treatment Plan - DIVAS 16 Liver Detoxification Reactive Phase 2 inter- Excretion mediates The rate limiting step Zinc, Vitamins A, B3, B5, B6, B12, C, E, beta-carotene and methylfolate. L-cysteine, L-glutamine, taurine N-Acetylcysteine, sodium sulfate, L-glutathione BILE & URINE EGCG: green tea catechins STOOL *DETOXIFICATION IS ENERGY DEPENDENT: quality carbs and proteins needed *Correct constipation prior to detoxification WATER ……. The original energy drink! Treatment Plan – DIVAS 17 u V – “VEG OUT” Acne, Hirsutism, Stress Clitoral Enlargement, Male Hair Pattern Overproduction of CRH & Cortisol Clinical Converts More Disruption Excess LH Elevated Excess Hyperandrog Depressi Elevated Excessive Androgen of & Normal Androgen enism on Adrenal Blood Insulin Hormone GnRH Insufficient Menstrual To Estrogen Cortisol Glucose Secretion Production FSH Cycles Levels Cease Elevated Androgen Production Increased Insulin Pancreatic Metabolic Centripetal Resistance Insulin Syndrome Obesity Production Amenorrhea, Anovulation, Infertility MIND-BODY Medicine - DIVAS 18 uYoga uMindfulness Meditation uQi Gong uTai Chi uCognitive Behavioral Therapy uImagery, Visualization MIND-BODY Medicine - DIVAS 19 u Yoga was found to decrease anti-mullerian hormone, LH and testosterone in adolescents u Yoga was found to decrease anxiety symptoms in PCOS adolescents u Mindfulness decreases psychological stress, BP, glucose and inflammation and offers positive effects on the central and autonomic nervous system u RCT 2015: decreases saliv.cortisol, anxiety and depression. Improved QOL u Cognitive Behavioral Therapy beneficial for eating disorders. u More studies need to be done utilizing mind-body techniques to lower cortisol and address the dysfunctional HPA axis. Treatment Plan –DIVAS V- “Veg out” 20 u Mind Body Medicine Classes u Breathing Techniques u Go on a Media Fast u Flex Your Fun Muscle u Heart Math u Mobile Apps Treatment Plan - DIVAS 21 u V – VOICE u Throat Chakra: connects the heart to the head u Difficulty: speaking up, expressing truth, asking for help u PCOS challenge u Trouble connecting inside to outside. Spiritual Bridge u FOCUS: Alignment with Divine Will through responsibility for actions; creativity Treatment Plan - DIV S A 22 u A = ACTIVITY : “MOVEMENT MEDICINE” uIncreases insulin sensitivity uImproves Digestion uIncreases sensitivity of cells to thyroid hormone uIncreases Dopamine uReleases Muscular Tension uRaises HDL uDecreases Blood Pressure uIncreases vagal tone & decreases sympathetic modulation in PCOS patients Treatment Plan - DIVAS 23 u Have you ever seen an obese wild animal? They do not eat dessert or They don’t eat bread or sugar. Those that do packaged food. begin to develop human diseases. They move, a lot. The Learn about amount of stress that occurs movement when you confine an medicine animal is deadly. from your healthy dog Treatment Plan - DIVAS 24 Treatment Plan - DIV S A 25 u Acupuncture u Infertility and Amenorrhea u Pelvic Pain u Hormone Balancing and PMS u Stress Reduction u Constipation u Withdrawal from substance abuse u Acne u Weight Loss u Insomnia u Depression and Fatigue Sugar is a substance many abuse or are addicted to DIV S Treatment Plan - A 26 Treatment Plan - DIVAS 27 Treatment Plan - DIVAS 28 uAcupuncture u Very difficult to study in RCT u Decreases in anxiety, LH/FSH ratio, and testosterone. Improved menstrual frequency in PCOS u No difference between Sham and Acupuncture u Highly safe …. HOWEVER: avoid specific points during pregnancy which can stimulate labor Treatment Plan – DIVAS S- SLEEP 29 u Shortened sleep increases Ghrelin levels. u Ghrelin can inhibit GnRH and decrease fertility. u High Ghrelin increases appetite. u Liver function ( detoxification) has a circadian rhythm u Circadian Rhythm essential to stable hormone regulation u Increased risk of Obstructive Sleep Apnea in PCOS patients: STOP BANG u Home sleep study u Sleep apnea: fatigue, inability to lose weight, u Take the Epworth Sleepiness Scale Treatment Plan – DIVA - SLEEP S S 30 This a revision of the popular STOP BANG sleep apnea screening questionnaire. u Do you SNORE loudly? Yes or No u Do you often feel tired, fatigued, or sleepy during the daytime? Yes or No u Has anyone observed you stop breathing during your sleep? Yes or No u Do you have or are you being treated for high blood pressure? Yes or No u Are you obese/ very overweight – BMI more than 35 kg/m2? Yes or No u Age over 50 years old? Yes or No u Neck Circumference >16 inches? Yes or No u Are you male? Yes or No ______________________________________ u SCORE: u If YES to 0 – 2, then low risk of sleep apnea u If YES to 3 – 4 of the above, then you are at intermediate risk of having sleep apnea u If YES to 5 – 8 of the above, then you are at high risk of having sleep apnea Treatment Plan –DIVAS S- Sleep 31 u Adequate Sleep (9 hours?) If not: uSerotonin made in the gut and requires B6 uMagnesium glycinate or aspartate uChamomile tea, Lavendar, Valerian uMelatonin, Vitamin D uTaurine, Theanine, GABA, 5-HTP uMeditation u “The Relaxation Response” Herbert Benson, MD u Use amber glasses to decrease blue light exposure known to decrease melatonin. Treatment Plan – DIVAS 32 u S- SUPPLEMENTS u Ideally: “Food as medicine.” u Undergo a nutritional and/or genetic evaluation and/ or be tested. MTHFR, VDR, COMT u IF YOU USE SUPPLEMENTS: 3rd party tested and certified get the recommendation from a licensed experienced professional. Retest levels and watch Liver enzymes u Vitamin D: 67-85% of women with PCOS <20ng/ml. Vit D is a hormone activating 950 genes. u Magnesium 60% of us are deficient u B vitamins, water soluble, methylated forms of B9 and B12 often preferred Treatment Plan - DIVAS 33 u N-acetyl cysteine: benefit when used with Clomiphene citrate u Licorice: reduces testosterone by blocking 17-hydroxysteroid DH and 17,20 lyase. Watch BP, watch drug interactions. u Flaxseed reduces androgen levels u Saw Palmetto: anti-androgen effects, reduce hirsutism & hair loss u Cinnamon: potentiates insulin, facilitates weight loss u Fenugreek & Gymnema: improve hyperglycemia and lower cholesterol u Chromium and vanadium: improve hyperglycemia, watch quantities. u Milk Thistle used with Metformin -> improved effects. Improves ovulation u Dandelion root: vitamins &minerals great for skin and improves acne u Chasteberry: immediately effects the pituitary, symptomatic relief (caution)