the pcos puzzle

The PCOS PUZZLEAn Integrative Approach

to Putting the Pieces Together

PRESENTED BY: ELIZABETH BOARD, MD FOUNDER OF ATLANTA FUNCTIONAL MEDICINE, INC.

Agenda

uFunctional Medicine PrinciplesuExamine the PiecesuPut them togetheruCase Examples

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Inspiration and some fun

Functional Medicine Principlesu Biochemical individuality based on genetic and

environmental uniquenessu Patient centered versus disease centeredu 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

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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

We need a framework to properly organize all of this information

Diet Intestinal Health

Sleep

Mind Body Medicine

Voice

Activity

AcupunctureSupplements

Detoxification

Treatment PlanuWhat do these ladies have in common?

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They are all DIVAS !7

Treatment Plan

D = DIET, DETOXIFICATIONI = INTESTINAL HEALTHV = VEG OUT , VOICEA = ACTIVITY, ACUPUNCTURES = SLEEP, SUPPLEMENTS

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Treatment Plan - DIVASu D = DIET

u Elimination diet and REAL FooduEliminate: dairy, gluten, sugar, corn, fruit juice, processed foods, soy

uFavor low glycemic loaduEat unprocessed foodsuIf 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!

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Treatment Plan - DIVASu Elimination Diet

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Treatment Plan - DIVASu D = DIETu Anti-inflammatory diet and High Fiberu The Clean 15 and the Dirty Dozen www.ewg.orgu “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!

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The Clean 15 The Dirty DozenuAvocado uPapayauPineappleuCabbageuSweet

peasuOnionsuAsparagus

uKiwiuEggplantuGrapefruituCantalopeuCaulifloweruCornuHoneydewuMangoes

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• Apple• Strawberries• Grapes• Spinach• Cucumber• Potatoes• Snap peas• Nectarines

(imported)

• Cherry Tomatoes

• Sweet Bell Peppers

• Celery• Peaches

www.ewg.org

DIVAS – DietTypes of Hunger

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Treatment Plan – DIVAS-Detoxification

u First Step is to limit exposurev Avoid Bisphenol Av Check your makeup:

www.ewg.org/skindeepv Avoid heating plasticsv Avoid Propyl Paraben (in tortillas, muffins, diet

cakes, trail mix and dyes)v Avoid Butylated Hydroxyanisole or BHA in

chips, preserved fats and processed meatv Avoid Pesticides www.ewg.org

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Treatment Plan - DIVASu I = INTESTINAL HEALTH

uHealthy gut? Suspect if any gi sypmtoms.u“Gut Restoration” & Prebiotics and ProbioticsuHormone reabsorption riskuHigher prevalence of IBS compared to

controls uHerbal 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!

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Treatment Plan - DIVASLiver Detoxification

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Phase 2 ExcretionReactive inter-

mediates

BILE & STOOL

URINEZinc, Vitamins A, B3, B5, B6, B12, C, E, beta-carotene and methylfolate.L-cysteine, L-glutamine, taurineN-Acetylcysteine, sodium sulfate, L-glutathioneEGCG: green tea catechins*DETOXIFICATION IS ENERGY DEPENDENT: quality carbs and proteins needed *Correct constipation prior to detoxification

The rate limiting step

WATER ……. The original energy drink!

Treatment Plan – DIVASu V – “VEG OUT”

Stress

Clinical Depressi

onElevated Adrenal Cortisol

Elevated Blood

Glucose Levels

Excessive Insulin

Secretion

More Androgen Hormone

Production

Converts Excess

Androgen To Estrogen

Disruption of

GnRH

Excess LH &

Insufficient FSH

Hyperandrogenism Normal

Menstrual Cycles Cease

Insulin Resistance

Increased Pancreatic

Insulin Production

Centripetal Obesity

Metabolic Syndrome

Elevated Androgen Production

Overproductionof CRH & Cortisol

Amenorrhea, Anovulation, Infertility

Acne, Hirsutism, Clitoral Enlargement, Male Hair Pattern

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MIND-BODY Medicine - DIVAS

uYogauMindfulness MeditationuQi GonguTai ChiuCognitive Behavioral TherapyuImagery, Visualization

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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 systemu RCT 2015: decreases saliv.cortisol, anxiety and depression.

Improved QOLu 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”u Mind Body Medicine Classes u Breathing Techniquesu Go on a Media Fastu Flex Your Fun Muscle u Heart Mathu Mobile Apps

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Treatment Plan - DIVASu V – VOICEu Throat Chakra: connects the heart to

the headu Difficulty: speaking up, expressing

truth, asking for helpuPCOS challenge

u Trouble connecting inside to outside. Spiritual Bridge

u FOCUS: Alignment with Divine Will through responsibility for actions; creativity

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Treatment Plan - DIVASuA = ACTIVITY : “MOVEMENT MEDICINE”

uIncreases insulin sensitivityuImproves DigestionuIncreases sensitivity of cells to thyroid

hormoneuIncreases DopamineuReleases Muscular TensionuRaises HDLuDecreases Blood PressureuIncreases vagal tone & decreases

sympathetic modulation in PCOS patients

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Treatment Plan - DIVASuHave you ever seen an obese wild animal?

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Learn about movement medicine from your healthy dog

They don’t eat packaged food.

They move, a lot. The amount of stress that occurs when you confine an animal is deadly.

They do not eat dessert or bread or sugar. Those that do begin to develop human diseases.

Treatment Plan - DIVAS 24

Treatment Plan - DIVASu Acupuncture

u Infertility and AmenorrheauPelvic PainuHormone Balancing and PMSuStress ReductionuConstipation uWithdrawal from substance abuseuAcneuWeight Lossu InsomniauDepression and Fatigue

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Sugar is a substance many abuse or are addicted to

Treatment Plan - DIVASuAcupuncture

uVery difficult to study in RCTuDecreases in anxiety, LH/FSH ratio, and

testosterone. Improved menstrual frequency in PCOS

uNo difference between Sham and Acupuncture

uHighly safe …. HOWEVER: avoid specific points during pregnancy which can stimulate labor

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Treatment Plan – DIVAS S- SLEEPu 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 rhythmu Circadian Rhythm essential to stable hormone regulationu Increased risk of Obstructive Sleep Apnea in PCOS

patients: STOP BANGu Home sleep study u Sleep apnea: fatigue, inability to lose weight,

u Take the Epworth Sleepiness Scale

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Treatment Plan – DIVAS S- SLEEPThis 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

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Treatment Plan –DIVAS S- Sleepu Adequate Sleep (9 hours?) If not:

uSerotonin made in the gut and requires B6uMagnesium glycinate or aspartateuChamomile tea, Lavendar, ValerianuMelatonin, Vitamin DuTaurine, Theanine, GABA, 5-HTPuMeditation

u “The Relaxation Response” Herbert Benson, MDu Use amber glasses to decrease blue light

exposure known to decrease melatonin.

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Treatment Plan – DIVASu 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 certifiedget 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 deficientu B vitamins, water soluble, methylated

forms of B9 and B12 often preferred

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Treatment Plan - DIVASu N-acetyl cysteine: benefit when used with Clomiphene citrateu Licorice: reduces testosterone by blocking 17-hydroxysteroid DH and 17,20

lyase. Watch BP, watch drug interactions.u Flaxseed reduces androgen levelsu Saw Palmetto: anti-androgen effects, reduce hirsutism & hair lossu Cinnamon: potentiates insulin, facilitates weight lossu Fenugreek & Gymnema: improve hyperglycemia and lower cholesterolu Chromium and vanadium: improve hyperglycemia, watch quantities.u Milk Thistle used with Metformin -> improved effects. Improves ovulationu Dandelion root: vitamins &minerals great for skin and improves acneu Chasteberry: immediately effects the pituitary, symptomatic relief (caution)u Myo- and Chiro- Inositol: supports insulin signaling in the cell, relieves stress

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u S = SUPPLEMENTSuWhy Treat insulin Resistance?

uDecreases inflammationuDecreases estrogen production in fatuImproves estrogen metabolismuDecreases oxidative stress

Support Insulin Signaling:Mixed Vit E: alpha, beta, gamma, deltaCLA: conjugated linolenic acidLipoic acid, Inositol, Magnesium, Biotin

Treatment Plan - DIVASu S = SUPPLEMENTS

u Progestin with androgenic properties (NETA) increased insulin resistance, progesterone does not

u Vitamin D improves insulin resistance and decreases inflammation u Get your DETOX ON with these foods:• Artichoke: 6 oz whole artichoke or 150-600 mg of leaf extract •Pomegranate: 6 oz of juice, 1 fruit, 30-100 mg of ellagic acid •Watercress: 6 oz or 125 -500 mg of whole plant extract •Green tea: 2-4 cups or 50-150 mg catechins•Asparagus helps with liver drainage.•Broccoli and Cauliflower activate detoxification enzymes

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Treatment Plan – DIVAS 36u Metformin use during pregnancy in women w/ PCOS decreased the rate

of gestational DM by ~27%, whereas lifestyle modification reduced the risk of gestational DM by ~58%.

u MITOCHONDRIAL HEALTHu CoQ10: ubiquinone or ubiquinolu L- Carnitine: transports free fatty acids into the mitochondria -> energy. u B-2 and B-3, Magnesium, alpha-lipoic acid

u DECREASE INFLAMMATIONu Turmeric (mix with ghee, black pepper or phosphatidylcholineu Boswelliau EPA-DHA u GLA, but always take with twice as much EPAu Pineapple ( especially the stem), Tart Cherries, Almonds

Which Puzzle pieces will you use? 37

“If your PCOS could be helped by something besides fertility drugs or BCPs, would that interest you?” 99% responded yes

Diet Intestinal Health

Sleep

Mind Body Medicine

Voice

Activity

AcupunctureSupplements

Detoxification

Case Studies: #1 Mrs. Ku 30 years old, dx’d with PCOS, NASH, married and wants childrenu Treated at Atlanta Functional Medicine for 8 months,

PCOS SYMPTOMSBEFORE TREATMENT AFTER TREATMENT

Amenorrhea(no menstruation) 3 months into treatment, normal 28 day cycle

Was told couldn’t have children November 2015 due dateFatigue Began walking, then jogging Morbidly Obese Lost 89 poundsOn liver transplant list No longer necessaryOn Metformin in past, no benefit Off Metformin throughout her tx

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Case Studies

VITALS BEFORE DURING AFTER 2-17-15Weight 298 254 238 209Blood Pressure

145/105 132/89 122/78

BMI 42.3 36 34.2Multi-Symptom Questionnaire Score

177 128 117

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u Vitals and Lab Results LABS BEFORE AFTER 2-17-15

ALT 172 24 19 17

AST 230 25 21 20

Cholesterol 203 153 165 132

Triglycerides227 155 128 77

HDL 32 37 38 38

Estrogen 36.5 152 113 129

Fasting Insulin nc 22 18 15

Hgb A1C 5.9 5.3 5.1 4.9

Progesterone < 0.1 1.64 2.4 14.3

Vitamin D 30 109 51 50

Case Studies Mrs. KMETRIC 1-7-14 2-21-14 6-23-14 2-17-15

waist 44.0 41.5 39.75 nchips 49.5 47.75 45 ncWHR 0.88 0.87 0.85 ncTestosterone nc 29 28 21FSH/LH 4.4/15.7 4.8/11.7weight 298 254 238 209

Pregnant but didn’t know it yet

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Case #2 Miss S. 18 yo presents with anxiety, lack of focus, unable to lose weight, irregular cycles, PCOS dxMetric 2013 11-4-

20143-6-15 6-26-15 7-17-15

weight 144 143 140 137

Total Chol 220 275 181

LDL-P 1545 2062 1120

HDL-P 46.4 46 40

FSH/LH 3/22.7 3.9/21.1 3.1/5.8

Testosterone 56.1 35 53 13

Fasting Insulin

nc 16 24 13

Anxiety high Very high confident confident

periods irreg irreg reg reg

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Gut restoration Zinc carnosine & elimination diet.Ovaben (Inositol)CoQ10,Vit D,Berberine,Mag/K,Fish Oil, PhosphatidylcholineArmour

15 yo female oligomenorrhea, acne, moodiness, back pain, weight gain. . Treated w acupuncture, back pain resolved. Placed on Elimination Diet, gut restoration program, Vit D

October 2013 December 2014 February 2014Testosterone 69.6 54.4 31Estradiol 90 102.5 217FSH/LH 8.4/16.9 2.3/9weight 136.2 132 135.2cycles -0- regular skippedskin acne improvedMSQ 58 27 15attitude moody improved Missed S.A.D.

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Case Studies 43

u Major factor that impacts outcome –COMPLIANCE!

References1. Borissova AM, et al. The effect of vitamin D3 on insulin secretion and peripheral sensitivity in type 2 diabetic patients. Int

J Clin Pract. 2003;57:258-261.

2. 2.Chiu KA, et al. Hypovitaminosis D is associated with insulin resistance and beta-cell dysfunction. Am J Clin Nutr 2004;79:820-108.

3. 3.Pittas AG, Lau J Hu FB et al The role of vitamin D and calcium in type 2 diabetes. A systematic review and meta-analysis. J Clin Endocrinol Metab. 2007;92:2027-2029

4. Thomson, RL: Vitamin D in the Aetiology and Management of Polycystic Ovary Syndrome. Clin Endocrinology. 2012;77 (3):343-350.

5. Nagarathna, PKM, et al. A Detailed Study on Poly Cystic Ovarian Syndrome and Its Treatment with Natural Products. Intl J of Tox and Pharm Research. 2013-14;5(4): 109-120.

6. "Risk of venous thromboembolism in women with polycystic ovary syndrome: A population-based matched cohort analysis," by Steven T. Bird, Pharm.D., M.S., Abraham G. Hartzema, Ph.D., Pharm.D., James M. Brophy, Ph.D., M.D., and others in the February 5, 2013, Canadian Medical Association Journal 185(2), pp. E115-E120

7. Textbook of Functional Medicine , 2013 The Institute for Functional Medicine

8. Lim CE, et al. Acupuncture for polycystic ovarian syndrome. Cochrane Database Syst Rev. 2016 May 3; (5).

9. Raja-Khan N, Stener-Victorin E, et al. The physiological basis of complementary and alternative medicines for polycystic ovary syndrome. Am J Physiol Endocrinol Metab. 2011 Jul;301(1):E1-E10.

10. Ram Nidhi, Venkatram Padmalatha,1 Raghuram Nagarathna, and Ram Amritanshu. Effect of holistic yoga program on anxiety symptoms in adolescent girls with polycystic ovarian syndrome: A randomized control trial. Int J Yoga. 2012 Jul-Dec; 5(2): 112–117.

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References (cont)11. Nidhi R, Padmalatha V, Nagarathna R, Amritanshu R. Effects of a holistic yoga program on endocrine

parameters in adolescents with polycystic ovarian syndrome: a randomized controlled trial. J AlternComplement Med. 2013 Feb;19(2):153-60.

12. Correa JB1, Sperry SL, Darkes J. A case report demonstrating the efficacy of a comprehensive cognitive-behavioral therapy approach for treating anxiety, depression, and problematic eating in polycystic ovarian syndrome. Arch Womens Ment Health. 2015 Aug;18(4):649-54.

13. Stefanaki C1, Bacopoulou F, Livadas S, Kandaraki A, Karachalios A, Chrousos GP, Diamanti-KandarakisE. Impact of a mindfulness stress management program on stress, anxiety, depression and quality of life in women with polycystic ovary syndrome: a randomized controlled trial. Stress. 2015 Jan;18(1):57-66

14. JC1, Costa EC2, da Silva E3, Tamburús NY3, Porta A4, Medeiros LF5, Lemos TM6, Soares EM7, Azevedo GD8. Aerobic exercise improves cardiac autonomic modulation in women with polycystic ovary syndrome. Int J Cardiol. 2016 Jan 1;202:356-61.

15. Lindheim L, Bashir M, Münzker J, Trummer C, Zachhuber V, Pieber TR, Gorkiewicz G, Obermayer-PietschB. The Salivary Microbiome in Polycystic Ovary Syndrome (PCOS) and Its Association with Disease-Related Parameters: A Pilot Study. Front Microbiol. 2016 Aug 25;7:1270.

16. Mathur R1, Ko A, Hwang LJ, Low K, Azziz R, Pimentel M. Polycystic ovary syndrome is associated with an increased prevalence of irritable bowel syndrome. Dig Dis Sci. 2010 Apr;55(4):1085-9.

17. Zangeneh FZ, et al. Synchrony between ovarian function & sleep in polycystic ovary syndrome patients. Open Journal of Obst and Gyn, 4, 725-731

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Thank youu For additional questions or comments, please

contact Elizabeth Board, MD at: Atlanta Functional Medicine, Inc. 5755 North Point Parkway

Suite #74Alpharetta, GA 30022770-667-3006Contactus@Atlantafunctionalmedicine.comwww.atlantafunctionalmedicine.com

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Appendix – MSQ 48AREA SYMPTOM AREA SYMPTOM

HEAD Headaches DIGESTIVE Nausea, vomitingFaintness TRACT DiarrheaDizziness ConstipationInsomnia Bloated feeling

EYES Watery or itchy eyes Belching, passing gasSwollen, reddened or sticky eyelids HeartburnBags or dark circles under eyes Intestinal/stomach painBlurred or tunnel vision (does not include near or far-‐sightedness)

JOINTS/ MUSCLE Pain or aches in joints

EARS Itchy ears ArthritisEaraches, ear infections Stiffness or limitation of movementDrainage from ear Pain or aches in musclesRinging in ears, hearing loss Feeling of weakness or tiredness

NOSE Stuffy nose WEIGHT Binge eating/drinkingSinus problems Craving certain foodsHay fever Excessive weightSneezing attacks Compulsive eatingExcessive mucus formation Water retention

MOUTH/ Chronic coughing UnderweightTHROAT Gagging, frequent need to clear throat ENERGY/ Fatigue, sluggishness

Sore throat, hoarseness, loss of voice ACTIVITY Apathy, lethargySwollen or discolored tongue, gums, lips HyperactivityCanker sores Restlessness

Appendix – MSQ 49

AREA SYMPTOM AREA SYMPTOM

SKIN Acne MIND Poor memoryHives, rashes, dry skin Confusion, poor comprehensionHair loss Poor concentrationFlushing, hot flashes Poor physical coordinationExcessive sweating Difficulty in making decisions

HEART Irregular or skipped heartbeat Stuttering or stammeringRapid or pounding heartbeat Slurred speechChest pain Learning disabilities

LUNGS Chest congestion EMOTIONS Mood swings

Asthma, bronchitis Anxiety, fear, nervousnessShortness of breath Anger, irritability, aggressivenessDifficulty breathing Depression

OTHER Frequent illnessFrequent or urgent urinationGenital itch or discharge

the pcos puzzle

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