Episode 58: Getting to Know Your Cysters – PCOS

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Welcome to Supplementing Health, a podcast presented by Advanced Orthomolecular Research. We are all about applying evidence based and effective dietary lifestyle and natural health product strategies for your optimal health. In each episode, we will feature very engaging clinicians and experts from the world of functional and naturopathic medicine to help achieve our mission to empower people to lead their best lives naturally.

[01:10] Most women have experienced the unpleasant symptoms that come knocking monthly with Aunt Flow. Some women however these symptoms are magnified due to serious hormonal imbalances. AOR’s Advanced PCOS Relief provides Myo-inositol, d-chiro-inositol along with a bio available form of folic acid to support healthy ovarian function and improved egg quality. It also helps to normalise the menstrual cycle, balance mood and aids in regulating metabolic factors. Find balance today with Advanced PCOS relief available at your local retailor or online at AOR.ca.

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 [01:42] Cassy Price:  Hello and welcome to Supplementing Health. I’m very excited to have Dr. Tracy Malone and Dr. Jennifer Fitzgerald joining me today to discuss Polycystic Ovarian Syndrome or PCOS. Dr. Malone and Dr. Fitzgerald are the co-founders of Conceive Health in Ontario and their clinic combines conventional and naturopathic medicine to help patients optimise their fertility. Welcome ladies. Thanks for joining me today.

[02:03] Dr. Tracy Malone: Thanks for having us this morning.

[02:07] Cassy Price:  Let’s start right at the beginning of what is PCOS?

[02:13] Dr. Tracy Malone: What is PCOS? So, I will give you a little bit of background about where I am coming from. I am a naturopathic doctor and I have been in practice for about 15 years. Pretty much I have exclusively done women’s health almost my entire active career. Now, I work in a very fertility focused clinic. So, I see this condition all the time in my practice. The first thing that people need to recognise about PCO which would be Polycystic Ovaries or PCOS is that it is an endocrine condition that affects females. It typically presents early on in menstruation and there are signs and symptoms that you should be able to pick up even without going to a doctor that would give you some indication that you might be manifesting PCOS or Polycystic Ovarian Syndrome. The first clue is that your period isn’t very regular, right? You would have missed periods or maybe you didn’t get a period at all when you were a teenager and going through puberty.

[03:36] Maybe you only got one every three months or maybe you got one every two months. So, the cycle regularity is all over the place. The reason for that is because there is an irregular ovulatory pattern. So, the dominate follicles that look to ovulate that month isn’t developed or isn’t developing on the expected timeline likely due to hormone deception so then it is doesn’t ovulate on time and because of that you have a longer cycle or no cycle because you haven’t ovulated at all. Then the third criteria would be excessive hair growth which is terms hirsutism. So, this could manifest itself in so many different ways in patient population.

[04:28] Sometimes I don’t see it at all and sometimes it is quite evident because they can have facial hair on your lip or on the jaw line area. You can have increased hair on the abdomen or down the midline and around the areola. Those are areas where you may see excessive hair growth. This is, as you will find out later as our discussion goes on, how to deal with that disruption and oestrogen and androgen ratio. It is the androgen, so the testosterone, that drives that symptom of hair growth. She may or may not be overweight or have gained weight in the last little while. That will really set off or amplify those other symptoms that I just listed. She may experience thinning hair and she may have acne. Those are the typical criteria that might identify a patient that has PCOS and what might lead her to go to the doctor to start investigation.

[05:37] Cassy Price: Okay, you said you see this fairly frequently in your practice so what percentage of women are actually affected by PCOS?

[05:46] Dr. Tracy Malone: I would say in my practice probably it is so common in my practice I am going to say 40%. Jennifer, would that be fair?

 [06:00] Dr. Jennifer Fitzgerald: I would say in our practice yes. In general population it is more like 10%. In fertility population you are going to see a much higher incident of that.

[06:13] Dr. Tracy Malone: My patient base are people who are trying to get pregnant so I get it would be skewed in my particular demographic.

[06:20] Cassy Price: That makes sense for sure.

[06:23] Dr. Tracy Malone: It is incredibly common. It is commonly missed or undiagnosed. It can go undiagnosed for a long time.

[06:36] Cassy Price: On that note, I was going to ask if there was an age where women are usually diagnosed with PCOS or can it go undetected for years?

[06:45] Dr. Jennifer Fitzgerald: It can go undetected for a couple of years for sure, I think. It is an endocrine disorder. It has perhaps genetic predispositions sometimes and then what I would call the epigenetic influence where our diet and our lifestyle could contribute to or exacerbate our genetic tendencies. So, in those cases, if somebody lived a really clean lifestyle and ate really well and exercised, they might not display those components of PCOS that might contribute to weight gain as much as somebody who didn’t lead that kind of a lifestyle. That might be displayed differently. We will see dormant PCOS where it is being controlled by lifestyle. In other situations, maybe that woman would have the symptoms of but because she is controlling it so well it is not being displayed. Does that make sense?

[07:46] Cassy Price: Absolutely. That makes sense. A lot of those symptoms in themselves could happen for other reasons as well, right? You could miss a period due to stress. How do you know that those symptoms actually are playing into PCOS verses maybe endometriosis or other potential gynaecological issues?

[08:09] Dr. Tracy Malone: So, when you’ve got the patient in the clinic, first of all I think young women and teenagers show up at their family doctors with either irregular periods or acne and the first major knee jerk to help ameliorate those two symptoms of irregularity and acne is to put her on birth control. When you put her on birth control you give her a steady stream of oestrogen and she appears to have a normal menstrual cycle because of the addition and removal of her birth control will make her cycle and it will often clear up her acne as well. A lot of those women go totally undetected until they come off the birth control pill, right? As far as diagnosis is concerned. If they were sent maybe for an ultrasound you might see on ultrasound and this is the difference between PCO, Polycystic Ovaries and PCOS. You can have Polycystic Ovaries on ultrasound which is the neurotheological characteristic of the ovary.

[09:22] When you look on a transactional ultrasound you will see that the two Cs of the ovary or the volume of the ovary is enlarged typically usually above ten ccs, I think it is. Anything above that would be considered enlarged. Then you will also see that they have a super high follicle count so by follicle too I mean that you will do a transactional ultrasound and you can see the follicles that are coming up to the plate for development and count them. If a woman would have more than 12 to15 on both sides she would be considered to have Polycystic Ovaries despite having no active cysts there at all. She may very well have a regular cycle, right? She has polycystic ovaries on ultrasound. PCOS, the syndrome, she is also going to be carrying along some of those other symptoms, likely acne, they call it Oligo ovulation which means it takes a long time for her to ovulate so she might not ovulate on day 14, she might ovulate on day twenty through40 depending on how long her cycle is and that is what causes the disruption in the irregularity of the period.

[10:45] Cassy Price: Okay. Outside of fertility issues how can PCOS or PCO affect a woman’s health?

[10:56] Dr. Tracy Malone: There are so many ways.

[10:57] Dr. Jennifer Fitzgerald: So, I mean the metabolic fallout of PCOS would include insulin resistance so your dysregulation with blood sugar and potentially being hyperglycaemic or hypoglycaemic and potentially developing type 2 diabetes as a result of that. From a metabolic perspective it also contributes to things like cardiovascular disease and high blood pressure and cholesterol issues and those types of things. It really does impact their metabolic health quite significantly if it is not controlled.

[11:36] Dr. Tracy Malone: I would say that the worst in a sense their metabolic state gets the more exaggerated the PCO symptoms. I think one of the cool things that you can always tell, we call them, cysters that you can lose at little as 5% of your body weight which is usually only five to 10 pounds and totally trigger your ovulatory function again.

[12:14] Cassy Price: Okay. Interesting. Are lifestyle changes and hormones, like you said losing weight, but are hormones usually the main way that you treat someone with PCOS or are there other treatment options or lifestyle options that help to manage and control those issues?

[12:34] Dr. Jennifer Fitzgerald: Based on research actually the best intervention for PCOS is diet and lifestyle changes so controlling the insulin resistance, basically is the best way to start. Even when they compare things like medication to natural treatments often especially from a fertility perspective there is more success with lifestyle intervention than there is with medical treatment.

[13:03] Dr. Tracy Malone: You have to be specific. At the base of it all PCOS in my opinion is in part a glucose disorder and you know if you consider insulin being a hormone as well one of the lifestyle factors that I always enforce with my patients is that they want to start weightlifting usually unless they are lean PCO for lean PCOS or as a tag term it is called ‘skinny PCO’ these might be atypical PCO patients verses Polycystic Ovarian Syndrome patients. These patients have a normal BMI and typically low end and maybe lower end like 19 or 20 or below and they will cycle normally typically. They will have a regular cycle without any issue, but they can also have issues with egg quality and ovulatory patterning although they won’t pick it up typically unless they go in for an ultrasound, right?

[14:12] That is where you end up seeing it morphologically. Treatments are similar but it is for those patients a lot about meal frequency and making sure they are getting adequate calories and not under consuming so at the base of it, it still is a glucose issue, but you would treat them differently from a diet and lifestyle. Instead of saying I want you to lose five or seven pounds, I want you to gain five pounds, and that will improve their hormonal profile and ovulatory regulation. Anyway, I wanted to mention that because I think the lean PCO patient is underdiagnosed and misunderstood often. So, if she is that traditional Rotterdam, the Rotterdam classification is the traditional PCOS patient who has no or long cycles, overweight, acne, hair loss and all of those she needs to put on lean muscle mass because the insulin receptors live in the muscle mass and the better you can sensitise and increase the concentration of her insulin receptors the faster you will help with her PCOS endocrine function as well because when your insulin is high which a lot of women with PCOS have this insulin resistance picture because they are young so they may not display full blown diabetes or haemoglobin may be normal but if you look at their ratio it is between fasting glucose and their fasting insulin often times that number clicks up above the ratio and that will display that she is indeed insulin resistant.

[15:54] When you have that accumulated insulin within your system, that interacts with your ovaries to cause the cells there to produce more testosterone and around and around we go. We have this insulin resistant high insulin testosterone circle which causes all of these symptoms. At the base of it she needs to reduce certain types of carbohydrates in her diet and recall or reduce not eliminate and then she also needs to weight lift and get adequate protein, so she has a hope to bring up her muscle mass. That is a key component of PCOS treatment from a lifestyle perspective.  

[16:44] Cassy Price: So, are those the key components to the PCOS diet? If you search PCOS online or you hear people talking about it there is what is referred to as the PCOS diet, is that mostly just reducing your sugars and helping balance that insulin resistance or is it more than that?

[17:03] Dr. Tracy Malone: I think it is a little bit more than that. I think for sure that is the base of it. I usually get my patients to come away from grains and do more plant-based carbohydrates and high proteins but there is an element in PCO of inflammation so those PCO diets out there do target inflammatory function because of the endocrine disruption and the metabolic disruption Polycystic Ovarian patients tend to be prone to inflammation which is sort of the connectivity to the cardiovascular component of the condition. You will see them being reduced daily saturated fats and those types of things as well.

[17:56] Cassy Price: Cool. So, jumping back a little bit to the cyst specifically, what causes them to burst and what happens if they do burst?

[18:07] Dr. Jennifer Fitzgerald: Well, a cyst that bursts are usually not necessarily a cyst that is associated with our typical PCOS type patient, right? A burst or a ruptured ovarian cyst is typically what you are going to refer to as a functional cyst and those are growing in response to oestrogen and are creating other types of issues. You don’t typically see that in PCOS patients in terms of the increase in the size and rupturing like that. That would be an a-typical thing to see in PCOS.

[18:43] Dr. Tracy Malone: You might see it once in a while, but it wouldn’t happen to her every month maybe.

[18:47] Dr. Jennifer Fitzgerald: Potentially, like you might see that in a fertility clinic setting where they have been stimulated with fertility medications. You might see that a bit more often, but I wouldn’t expect to see that routinely in a PCOS patient.

[19:00] Dr. Tracy Malone: But when you do, occasionally we do, they are called haemorrhagic cysts when they burst and they hurt and she will often feel it and she might have tenderness or pain prior to or surrounding ovulation and a lot of times if it is a significant size cyst she will take herself off to the ER thinking she has appendicitis. That is how painful they are. Sometimes they cause spotting. It is rare for it to go on and on or monthly as Jennifer said. Usually, cysts happen and they come and go and sometimes we will catch them on ultrasound and you know these can absolutely be driven by lifestyle as well so if she is drinking a lot of alcohol and coffee and things that would inhibit or alter her oestrogen metabolism. She might be more likely to develop cysts is she is prone.

[20:07] Cassy Price: So, if your PCOS goes undiagnosed how does that impact your fertility?

[20:14] Dr. Jennifer Fitzgerald: It delays or prevents ovulation so if a woman is having an irregular menstrual cycle so say she is ovulating late, what that tells us clinically is that particular egg is taking too long to grow. Typically, we would ovulate a healthy egg by day 14 of a normal menstrual cycle. Any egg that would be ovulating beyond day 17 or 18 we would be questioning the quality of that egg, right? It is taking too long to mature so therefore it is not getting the right signals and it is potentially a low energy oocyte or something along that nature. If you see a woman that doesn’t cycle for every three months, she is probably not ovulating at all, right? In order to leave to must ovulate that is step number one. That is why it makes it so difficult for PCOS women to become pregnant as either the absence or the delay in ovulation makes it very difficult for timing and then when they do ovulate it is not necessarily a good egg.

[21:22] Dr. Tracy Malone: Then you have to go on the hunt for what is the hormonal disruption. This is when you come into the variances sense of the PCOS or PCO expression. Sometimes, it is that their insulin is totally wacked, and it is too high and they need to go after a metabolic type of treatment plan with them to get them to ovulate regularly. Sometimes their androgen, their cycle is regular, but their androgens are through the roof and that can really interfere with maturation of the egg. So, we have to go then and do some testing to be able to tease out what kind of PCOS does she have.

[22:17] Cassy Price: Once a woman gets pregnant if she has PCOS are there any potential risk factors during pregnancy or any influences that the PCOS has?

[22:28] Dr. Jennifer Fitzgerald: For sure. Women with PCOS would be more likely to develop gestational diabetes for one. They have a higher risk of things like preeclampsia or pre-term labours. High blood pressure during pregnancy and those types of things and not having normal birth weight babies so larger babies.

[22:54] Dr. Tracy Malone: For sure as we know if we go into the glucose disruption we know if she is vulnerable to it genetically. I don’t mind sharing I am a PCO patient, and I had gestational diabetes for sure in my third pregnancy and had a 10 and half pound baby. I am one 130 pounds, so it is a tricky condition. Now, because that happened, I am 75% more likely to become a type 2 diabetic in my adult life.

[23:31] Dr. Jennifer Fitzgerald: Potentially if it is uncontrolled during pregnancy, they do see effects on the children in terms of an increased risk for higher cholesterol diabetes themselves and those types of conditions.

[23:46] Dr. Tracy Malone: That is called genetic imprinting or epigenetics. I also don’t mind sharing that I have three children and my first two pregnancies I had no gestational diabetes, in my third pregnancy I had gestational diabetes, but I was well controlled. Despite that I had a 10-and-a-half-pound baby so it was macrosonomic, they call that a big birth weight baby. She had a little bit of glucose fluctuations at birth and an ASD defect which is a heart defect. Although things like that run in my family they contributed to the gestational diabetes. It closed and is totally normal now but none of my other children manifested it, so I have to think that it was due to the environment.

[24:36] Cassy Price: A mother’s health definitely influences the development of the baby on all fronts, just like the diet and everything that the mom is taking in it feeds the babies development so it makes sense that something like this would also play a role in their development to a certain degree, right?

[24:53] Dr. Jennifer Fitzgerald: The good news is that if we control it during pregnancy, it does lessen those risk factors so that is the key. If we can catch on and control it and diagnosing PCOS early and getting it under control prior to pregnancy is ideal but even if not working on it and working with a health care provider during pregnancy to control those values as well.

[25:17] Dr. Tracy Malone: Yeah. We would always encourage a lifestyle technique first and adjunctively in our clinic, we work in an IVF clinic so a lot of times the first knee jerk reaction is medication for PCOS is metformin, right? So, metformin shows it has efficacy on ovulatory regulation and it impacts the insulin and glucose sensitivity of the patient and it helps to remove weight. So, those two things before you get pregnant are really important because we know that those patients are really going to be vulnerable during pregnancy to gestational diabetes, so I always say do it now, so you don’t have to do it later.

[26:05] Cassy Price: Right. Another supplement that I have heard commonly used for PCOS patients is inositol. Do you guys use that in your clinic and what does it do for PCOS?

[26:16] Dr. Jennifer Fitzgerald: We use a great deal of inositol in our practice including for PCOS. It is a sensitiser to the insulin essentially. It helps the body be more sensitive to it and be more sensitive to the glucose, so it helps it utilise both insulin and glucose better. It has a regulatory effect on some of the hormones as well so we mentioned things like androgens like testosterone during the conversation so not only can it lower things like insulin but also things like testosterone if it is elevated or other androgens as well. It has a positive effect on lipids as well in some of the research. It shows an effect on LDL triglyceride ratios and levels and helps to normalise those. It does hit a lot of the different angles.

[27:08] Dr. Tracy Malone: It has a good impact on mood too. Some people use it for mood and that is something I think should be recognised in a PCO or PCOS patient. She is prone to anxiety and depression and by controlling some of the hormones and normalising that some of the glucose sensitivity she will notice a reduction in the anxiety and low mood. Inositol may have an effect on the mood as well. I have also read papers about Inositol specifically to egg quality so sometimes I will give an egg quality patient inositol because research demonstrates that the higher the level of inositol inside the follicle and the follicular fluid the better the quality of the eggs.  

[28:05] Cassy Price: Androgens are often thought of as having a big impact on sex drive and libido in general so when you come across PCOS patients do you find their libido is affected and does treatment help or hinder that in any way?

[28:26] Dr. Tracy Malone: That is a good question.

[28:28] Dr. Jennifer Fitzgerald: Definitely. So, libido is multifactorial for sure when it comes to hormones and endocrine systems so androgens are one component of it so we might hear if we have low DHEA or low testosterone you might have low libido but it doesn’t go the other way necessarily where if you had high testosterone and high DHEA you might have high libido, you might still see a very low libido in those patients because their oestrogen is also so low, right? Typically, yes when you start correcting and normalising the hormones you do see a return on the libido.

[29:03] Dr. Tracy Malone: That is a good point to make. I think specifically when you get her ovulating, she notices a pickup in her libido.

[29:13] Cassy Price: Fertility is obviously a two-person job to actually procreate so is there a version of a male style PCOS? Obviously, they don’t have PCOS because they don’t have ovaries, but they do have their testes and they function is a somewhat similar way. Do they have something that is similar that could affect them?

[29:37] Dr. Jennifer Fitzgerald: Not really in the same kind of way. Men are more likely to see low hormones like more of an andropause type situation or it is usually structural or a varicocele or something like that. You can see a cyst in a testicle here and there, but it would be pretty uncommon.

[30:00] Dr. Tracy Malone: I think more specifically he would probably be diagnosed with diabetes or prediabetes kind of thing and then you will see augmentation in his semen analysis and motility specifically and count sometimes.

[30:16] Cassy Price: Okay. We have been learning more about metabolic syndrome as well. Is there ever a misdiagnosis of PCOS as met s or vice versa that has to be corrected or can they be misdiagnosed and still end up addressing the root issue?

[30:34] Dr. Tracy Malone: I think if you address metabolic syndrome, you will be addressing a lot.  I think it depends on how you are treating it. If you are treating it with pharmacy, it is not going to help with PCOS. I mean if she has metabolic syndrome and they put her on Lipitor and a high blood pressure medication it is not going to make her PCOS any better but if they treat her metabolic syndrome with a nutritional lifestyle and she corrects her body compositions then that is going to influence her PCOS.

[31:01] Cassy Price: What would be some of your key tips for someone who is just trying to figure out if they have PCOS and wants to manage it until they get a diagnosis?

[31:11] Dr. Jennifer Fitzgerald: So, if they are yet to have a diagnosis and want to manage it in the meantime, I would start with diet and exercise so moving your body in terms of the exercise and start building lean muscle mass so lifting weights like Tracy mentioned earlier. It is a really good place to start with that but moving in general. So, you are trying to increase lean muscle mass in order to increase the number of insulin receptors in your body is the bottom line there. Any movement is better than no movement. Starting to eat what we would call a low glycaemic diet so that is where moving a lot of the simple carbohydrates out of our diet. We would normally go as far as to say remove a lot of or all grains from your diet to start. That will very quickly make somebody’s diet low glycaemic because wheat breaks down into sugar not because it has gluten in it.

[32:09] We are trying to eliminate one of the main contributors of sugar essentially and the most direct route of. We don’t want to take fruits and vegetables away because they have so many health benefits to them and that is where antioxidants lie and the good anti-inflammatory properties, so we want to remove grains which tend to be more inflammatory and cause more of a blood sugar index spike. We remove those things, and we focus on our good carbs and our healthy proteins and healthy fats. That is the foundation of PCOS care.

[32:50] Cassy Price: Is there a specific test that a woman should ask for if they suspect that they have PCOS and they are talking to their family physician and want to uncover that?

[33:01] Dr. Tracy Malone: The most obvious test is an ultrasound. That will tell you fairly quickly. Again, you can see the characteristics on the ultrasound. Then you can also have a hormonal test that you can get done so for example AMH, anti-malarian hormone, is the test that you can have done. In the clinic it is known as the ovarian reserve test. In PCO patients or Polycystic Ovarian patients it will be elevated for age and then you can test androgens right?, This blanket term of androgens so testosterone or DHEA and sometimes high testosterone but just start with the basics to see if any or all of those are elevated. Usually, it is one and the rest of them are just high normal.

[34:04] Dr. Jennifer Fitzgerald: Insulin and blood sugar screen I would look at initially as well.

[34:10] Dr. Tracy Malone: If they are higher as well.

[34:11] Dr. Jennifer Fitzgerald: The cholesterol panel as well to look at their cholesterol values and then also in terms of the hormones we work in a fertility clinic so often you would have their day three hormone profile available to you and you might see a skewed ratio in their LHFSH ratios on their day three. We are always looking for that high level of LH on day three and then the FSH and that will steer me into looking a little bit further for that particular person.

[34:40] Cassy Price: Awesome. Thank you so much for sharing all of your knowledge on this topic. I think it is something that affects a lot of women and maybe isn’t as discussed as it should be, so I really appreciate you two taking the time to chat with me today. If our listeners want to work with either of you what is the best way for them to get a hold of you?

[34:59] Dr. Jennifer Fitzgerald: Our website probably, concievehealth.com. They can look and find our bios and all kinds of information just directly from there.

[35:10] Dr. Tracy Malone: Thanks for your time and the opportunity today.

[35:14] Cassy Price: Yeah. Thank you both I really appreciate it.

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