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Join us as we discuss an integrative approach to Polycystic Ovarian Syndrome (PCOS) with Dr. Felice Gersh. 10% of all women have PCOS, making it the most common female endocrine disorder and cause of female infertility in the world. Women with PCOS may suffer from acne, menstrual irregularity, infertility, obesity, autoimmune disease, diabetes, and heart disease. Traditionally, doctors treat symptoms one at a time, often with a new regime of pills for each symptom or an invasive surgery. This approach never addresses the underlying causes of PCOS so women are medicated but never healed.
PCOS is not JUST a reproductive problem, there is a strong link between reproductive function and metabolic function. Dr. Gersh goes into great detail about how the two are related and how a woman with PCOS can start to make manageable changes in her life toward feeling better.
Felice Gersh, M.D. is board-certified in OB-GYN and Integrative Medicine. She taught as an Assistant Clinical Professor at the Keck USC School of Medicine for 12 years, and she is the founder and director of the Integrative Medical Group of Irvine. A globally recognized expert on women's health, she regularly speaks at conferences around the world. Dr. Gersh is the bestselling author of PCOS SOS.
Hello, and welcome to The Better Biome Podcast where we explore the universe within. I'm your host, Dr. Nicole Beurkens, and on today's show, we are talking with Dr. Felice Gersh about polycystic ovary syndrome and its connection to the microbiome. Dr. Gersh is a multi award winning Board Certified Obstetrician and gynecologist living in Orange County, California. She's the founder of the highly successful integrative Medical Group of Irvine and received her education from Princeton University and USC School of Medicine. With more than 40 years of experience in all matters relating to women's health. Her main area of expertise is hormonal management, specifically polycystic ovary syndrome. She held the post of Clinical Assistant Professor of OB GYN at the Keck USC School of Medicine and remains affiliated with the University of Arizona School of Medicine where she completed a fellowship in integrative medicine. She's also an expert reviewer for the Medical Board of California and a qualified forensic expert. Dr. Gersh is a prolific lecturer and author and has written the best selling books PCOS SOS, and PCOS SOS Fertility Fast Track. Such a pleasure to have you on the show today, welcome Dr. Gersh.
Well, thank you. It's a pleasure to join you here.
I'd love to start by having you share a bit about your journey. You have been doing this work for over 40 years with women at this point, and I'd love to hear how your professional endeavors have sort of led you to this point of focusing on the work that you are doing today?
Well, from the very get go, when I started my practice, I knew that there was more to helping women than just what I was doing, which was a lot. I was doing lots and lots, thousands of deliveries, and I did very high tech surgeries, and I was up to date on every pharmaceutical, but I knew there was more. So when I started my practice very early on, I incorporated a Chinese medicine practitioner, I had a psychologist, a nutritionist, I had a massage therapist, I did biofeedback. But I myself never had any additional training. It was after about a dozen years ago, I stopped doing obstetrics. And I did it because I just couldn't deal with the nights any longer. I didn't even know about circadian rhythm. I just knew that this was doing me in. But after I stopped doing obstetrics, I had more time, I had more sleep, And I started really looking at my therapeutic toolbox as a gynecologist and I asked: What am I doing? All I can do is surgery. Now I'm very good at surgery, but that's dealing with end stage disease. I want to be more proactive, I want to prevent women having to have surgery. And I didn't really have any tools, and the only thing that I seemed to prescribe, other than antibiotics for urinary tract infections, was birth control pills. And then I was doing hormone replacement therapy for menopause, and of course, then I had to do that almost on the slide because it was like, "No, don't do it." And it was like, there's something wrong here. And I felt very lost. And I started just searching the internet. I ended up taking courses with naturopaths in Portland, Oregon with Tori Hudson. I did a lot of her women's courses, and I felt very comfortable with this group. And I started feeling more distance from my own MD crowd. One time I was there and I had no real agenda, no plan. I just went and just learned what I could. There was another MD in the room. I was the only MD in the audience, and then there was an MD, Dr. Dr. Low Dog, she was the director at that time for the integrative fellowship at the University of Arizona School of Medicine. And I went up to her at the break and I said, "Dr. Low Dog, you and I are the only MD's in this room. I am so lost, I'm just randomly taking courses. I don't really know what to do. But I know that I have to make these changes in my practice and in myself." And after talking to me, she said, "I know you are qualified. You should do the fellowship. And guess what? The next term starts in two weeks." So when I flew home, I did the application, two weeks later, I was in Tucson, Arizona. I did the two year fellowship which I completed in 2012, and then I subsequently became — I'm now a consultative faculty member. So I'm actually affiliated with them and I sometimes do lectures there and I grade their finals, but it has changed everything for me. I just needed the beginnings. And since then I've never looked back.
And then I've taken loads of functional medicine courses, and taught myself different things, essential oils and guided imagery and all these other things. And years and years ago, it's sort of the dark side, I don't always share it, but I'm just telling you, I used to do a lot of lecturing for Big Pharma. But I really thought I was doing everything right. And now I think some of the drugs that I was actually promoting, I wish I could take it back. I'm kind of trying to do that now. But then I started going back to my roots as an educator, and I just started teaching, and now I lecture nationally, internationally, and part of my mission is to show women that there are other things out there. You can harness your own innate mechanisms, there are other therapeutic tools, that the solution to every female problem is not birth control pills, and is not surgery. And it's not antibiotics either. So I just feel like now I have so much more to offer. And that's why I'm so happy to be here with you today, so that we can share some of the new things that I have learned because I consider myself a synthesizer. I comb through everything: Environmental Medicine, veterinary medicine, whatever it is on PubMed, Google Scholar, and then I put it together, because we know conventional medicine is so fragmented. Everyone has this organ, and not even just this organ, it's this piece of this organ. You talk to a cardiologist, all they know, is the mitral valve. So I try to put it all together to create a whole, that sort of putting the whole in holistic medicine. And now I'm writing books and doing more lecturing, and that's my mission in life, is to help as many women as I can in my practice, where I see patients every day, but there's a limit to how many people I can see. So that's why we have to do these more global things, where we can reach more people this way.
Absolutely. And I really appreciate you sharing that piece about how you used to approach things and what you used to be doing, versus now, because I think for all of us as practitioners, there can be some defensiveness there when it comes to learning new things, right? "This is what I've learned in med school, or in my doctoral training, this is what I know", and sort of staying stuck there. And not exploring or taking advantage of new research and new things that are coming out. And I think for you to say "I did everything right with what I knew at the time. And then as I started to know more, and have my views expanded and delved into the research on other things, I expanded my practice with the tools that I was using, with how I was educating people." And I think that's really refreshing to hear from a physician, actually, that "This is what I was doing, but as my own knowledge expanded, then I am doing better. I'm doing different things with that now", and I think that's wonderful.
Well, and it is so exciting. We know that the incidence of physician burnout now in the US, I mean, it's all over the place, but some people say as high as 80%, but at least 50%. What is that saying? And they say that doctors who are burnt out are dangerous to themselves, but also to their patients, because they don't see patients as people anymore. They are annoyances. And when you move away from the conventional type of practice with the seven minute appointments, and the protocol-driven everything and "Here's your formulary", suddenly, it's wonderful again. So you love what you are doing. And the other thing that you mentioned is doctors getting stuck. There's data after data saying that once something is discovered scientifically, it's not even questionable. This is new information. It can take close to 20 years before it's implemented clinically, unless a big pharma recreates a drug. And then it's all over immediately. Then they push it, push it, push it. But my goal is no, women cannot wait another 20 years to learn about things like the gut microbiome, the vaginal microbiome. No. We have to speed things up, and we have to help doctors to not feel so stuck that they can open their minds to new things. And sometimes, and this is painful, like you said, say "What I was doing, maybe it wasn't really so great. Maybe all those pharmaceuticals were not really the answer to the problem. At best, they were covering up some of the symptoms, but they certainly weren't getting to the underlying root cause, they weren't dealing with the real issues at hand." So it's hard to say "I was wrong. I have to change." In gynecology, I questioned this from the beginning, but I still sometimes did it because you are under so much pressure. And it was you are doing a hysterectomy on a woman who is, say, 45. And it's for large fibroids and bleeding. So there could be a good reason for the hysterectomy, because there's just nothing you could do at that point. And then they would say, "Take out the ovaries." And I would say, "But they are normal." They say,"Well, they could become cancerous." It's like, "Yeah, but they are still working." And they said, "Well she will go into menopause soon." And now we know that that was a very bad thing to do. Very, very bad. So we just sometimes have to say there were things that were done. Sometimes they used to use lead, mercury, and arsenic. We just have to say "It was not a good idea. Nobody meant harm, but let's just stop it and move into something better." And so that's what we have to do. And we have to sometimes do it one doctor at a time, but we can. And the thing that's so amazing to me, is how educated and interested the population is. The people out there who, of course, can be patients, are more interested than sometimes the doctors. So I try to work on both avenues, the doctors and the general population. And sometimes the population is what pushes the doctors. So here we are, we are going to make this happen.
That's absolutely right. And I think that's a great point because a substantial amount of our audience for this show are consumers, patients, and people in the general population. And our mission is really to provide them with updated research, with education to empower them as people, as patients, to go to their health care providers and start those conversations. And sometimes I think that is how we affect change, is by patients going in and saying, "I heard about this, can we look at this? Tell me more about this. What can we do?" And I think that that's a powerful way to impact change as well.
And also to empower patients to say "You know what? I don't care what you say, Doctor, You are not my dictator." And that's the other thing, a lot of doctors were somehow ingrained with the idea that they are the boss of their patients. And I tell them your doctor is your consultant. You are the boss of yourself, and nobody can boss you around. You do what you think is right. But listen, and hopefully you find doctors that you trust, so that you want to take their advice. But if it sounds wrong to you, get another opinion. And no, don't let anybody try to belittle you, which sometimes happens.
It does. That partnership is really important. Well, I think one of the areas where this issue you mentioned in the past, we have put a lot of band aids on women's health issues, right? Surgeries or prescription birth control pills, those kinds of things just kind of cover it up. And what you are really doing now is looking more at root cause issues, being proactive. How do we really address some of these things? And one of the big things that we are seeing more and more in women now is polycystic ovary syndrome. So many women are struggling with that, and we have not had good root cause solutions to that. Many of these women have been just sort of poo-pooed with their symptoms for years or put on medications or things, and you really have delved into how can we actually understand what's going on here and really help these women. So let's dive into that topic a bit. First of all, for listeners who aren't aware, give us an explanation of what is polycystic ovary syndrome.
Well, it's the most common endocrine disorder of women, actually reproductive age women, but it actually starts in childhood. Probably the beginnings are in utero, and then it will continue through menopause. But the real focus and the symptoms are seen in reproductive-aged women. The name came from the look of the ovaries. So you have ovaries that are malfunctioning because of hormonal imbalances, and every month, it's a miracle — We don't really understand it all, but every month in a reproductive cycling woman, the the ovaries start recruiting eggs to develop into little follicles, and a whole bunch of them develop. And there's these different hormones called Anti-Müllerian hormone, which I think is a terrible name because it doesn't tell you what's going on. That's related to what it does when you are an embryo. So my push would be to change it into calling it follicle recruitment hormone, because that's really what it's doing, the Anti-Müllerian hormone, it's recruiting follicles. So this amazing thing is happening, and you have in a different part of the ovary, you are creating testosterone. And that's being pushed to be made by the pituitary gland putting out a hormone called luteinizing hormone. Then this testosterone moves into the granulosa cells where little follicles are developing, and through an enzyme called aromatase, that testosterone is converted into estradiol. Now, all of this is happening, and as this is happening the FSH from the pituitary, called follicle stimulating hormone, that then shuts down the Anti-Müllerian hormone. So that level goes down. And then this miracle thing happens, I call it the special one. The special egg that is going to be the ovulated one. And occasionally there's two, as we know, the occasional twins. That special egg then develops into the full blown follicle that is going to then ovulate, and the other follicles just regress. So it's kind of like there's a beauty contest, they're all lined up. And then it's like "You are the one!", and then the other ones move off to the side. And then it comes out. And that's the miracle. But in women with PCOS, the Anti-Müllerian hormone keeps being produced. That's one of the markers, is high levels of Anti-Müllerian hormone. So it keeps recruiting follicles. It's like, "Come on guys, more follicles, more follicles." And the enzyme, aromatase, is not functioning well, and the FSH levels are too low. So you are not making enough estradiol and you are not shutting down the Anti-Müllerian hormone. You are not picking that special one to ovulate, and you just keep recruiting more follicles. So these follicles accumulate around the cortex or rim of the ovary, creating the polycystic ovary syndrome look. And so that's where it's coming from when you see that on an ultrasound.
Now, not in a teenager — this is really important. If you do an ultrasound of a young girl, 14, 15, she is only just going through puberty still, really she's still developing. You will often see a picture that looks like PCOS, because her ovaries are on training rails. Sometimes their ovaries don't pick the special one, but not because they have PCOS, just because they are still practicing, they are still in the developmental phase. That's why you have to be very careful. Some girls are overdiagnosed because they get an ultrasound, and the doctors don't even understand what's going on.
I was going to ask about that. Because I've seen that in teens and young women.
So sometimes you really can't diagnose it by ultrasound in that young group, because their ovaries are just getting the hang of it. But in a woman when she's in her 20's, oh, for sure, that should not be happening. So that is one of the real clues, of course, is the ultrasound picture. And that's where the name came from. They have committees. Doctors may do that, that's what they do. They have committees. And so a committee met and they came up, not long ago, with sort of a new definition of what you have to have to get the label of PCOS. You need to have two of the following three: And this went against the androgen excess PCOS society's recommendation, which was that it should always include hyperandrogenism, like too much of the male type hormone, but that's actually not in the definition. That's not required anymore. So you have to either have the ultrasound finding that I described, with lots and lots and lots of these little follicle cysts all around the rim of the ovary. You have to have menstrual irregularity, some problem with your period or evidence either clinically or on a lab test of elevated androgens, that would be either and most commonly testosterone, but it can be DHEA sulfate,
dehydroepiandrosterone sulfate, which is an adrenal androgen. And in fact, just 13% of women with PCOS do not have elevated testosterone, they have elevated DHEA sulfate, and that's probably a different group. That's really a different group. They have an adrenal overproduction issue. They don't necessarily qualify as acquired adrenal hyperplasia, but there's something going on with the adrenal, and they often will not really have the ovarian finding. So it's a different — remember when you say syndrome, it kind of incorporates sometimes outliers of a little bit of a different group. But generally speaking, it's high testosterone. And of course, when you have high testosterone, oh my gosh, you are going to have some types of masculinization type features, which women hate, of course. How about having a male pattern baldness? Oh, my gosh, androgenic alopecia, and hirsutism. Nothing like having to shave every morning. And then the testosterone driven cystic recalcitrant acne, like the jaw line, this terrible deep cystic acne. It's so painful, high incidence of scarring, disfiguring. It doesn't respond to really any of the conventional treatments, including very low success rate with Accutane, which can actually trigger unrelenting, untreatable irritable bowel syndrome in women. So I mean, lots of problems there, and then liver problems, and they already can have fatty liver. So all kinds of issues there.
So that's sort of the the general presentation, but now we understand it's not just a reproductive problem, and in fact, one of the things that I look at with PCOS, it's sort of the poster child for the link between reproductive functions and metabolic functions, and what happens when everything goes wrong, because it's all linked together. And most doctors, including gynecologists, don't understand the link between reproduction and metabolism. And metabolism is the creation, distribution, and use of energy. I mean, that's what life is. So everything is metabolism. That's the spark of life, how you make energy, use energy and so on. And of course, they are linked, because nature wants women to be fertile and to be healthy. Because what's the point of a woman conceiving if she's not going to be able to survive, or she can't nurse the child? If she doesn't have adequate fat stores? She's not healthy, she doesn't have a functioning immune system? That type of thing. That's why women who have anorexia, their whole system shuts down. But women who have what we might call overnutrition, it's really they are usually malnourished, right? But they have too much body fat, and will have many, many reproductive problems, because nature desires successful fertility. And so when you have malfunctioning, you have it in the whole system. And that's what PCOS is. So if you look at the reproductive problems, you have major fertility — it is the most common cause of female fertility problems. And then you have all the menstrual problems, irregular cycles. And so you have all of that. And when women become pregnant, which does happen, of course. Women with PCOS are not sterile, they are just subfertile, and sometimes they go and sometimes they have IVF and they have other drugs, fertility drugs, but when they do have those treatments, by the way, they have a very high failure rate. They have one of the highest failure rates for IVF, and they should never even enter IVF until they are healthy, even if they have to do that, because they have high rates of failure. And when they do become pregnant, they have high rates of miscarriage, and every pregnancy complication that you can imagine: Gestational diabetes, preeclampsia, pregnancy-induced hypertension, preterm labour, abruptions, everything is at a much higher rate. So, that's all the fertility part.
But then there's the metabolic side. So women with PCOS are inflamed. Inflammation is the buzzword in functional integrative medicine, and that's where that microbiome will come in. So they are just chronically low level inflamed women. And that, of course, leads to insulin resistance. So they have high rates of insulin resistance. By age 40, women with PCOS have four times the incidents of diabetes in the average woman. Very high rates of diabetes, and all the [inaudible 0:22:54.8, right? So it's a terrible problem. And they have more endothelial dysfunction. So arteries have this lining called the endothelium, and that requires proper hormones and nitric oxide to be healthy, which requires proper hormones. And they don't have that. And so they have dysfunction of their arteries, which can lead to much higher rates of hypertension. And of course, arteries are the highways of the body. If you don't have a really healthy vascular system, then every organ is going to suffer because you are going to have problems. And that's why you can have renal problems, kidney problems. And, of course, there's also problems that women have with PCOS involving mood. They have high rates of mood disorder, high rates of sleep apnea, which is a sign of neuroinflammation, they have brain inflammation, and then they have, of course, more brain fog. And so and the sleep problems, not just even sleep apnea, all kinds of sleep problems. They have jet lag, they live a life of jet lag because of the neuro inflammation and the fact that they don't make enough estrogen. This is so key. So many doctors talk about PCOS and they use the words estrogen dominance. Well if you are going to say estrogen dominance because there's progesterone deficiency because they are not ovulating regularly, but that gives the wrong people the wrong idea, because study after study has shown: Because they have lowered amounts of FSH, they can convert testosterone well to estradiol. Now in ancient times, that existed. They have a genetic little blip here. But in ancient times, that was actually a survival advantage because they were still fertile, just maybe slightly less. So maybe instead of having eight children, they had five. That's a survival advantage. They had fewer chances of dying in childbirth, and childbirth and the whole pregnancy situation depletes women. They are taking All their iron out of their body and giving it to the baby, and it's hard to replace it. So it's depleting and it's potentially fatal, when people could bleed, get infections. And then they had more time with each child. So they could safeguard their children, they could nurse them longer so the children would be healthier. And then they had just a slightly elevated testosterone, because what happens is the brain says, "I want more estrogen." So the way estrogen is made is by making testosterone. All estrogen comes from androgen. So all estrogen in the ovary comes from testosterone. So the ovary is then stimulated by more LH. So the brain talks to the pituitary. The pituitary, then puts up more LH, which, by the way, is very common in women with PCOS. They have a high LH to FSH ratio. More LH. Because their brain wants more estrogen. So it just says more testosterone to make more estrogen, more testosterone. But it can't convert. So you are going down the assembly line, and then there's a block. Okay, so you back up. So you have the backup of too much testosterone, and then you don't get enough estrogen. So estrogen, it turns out, is everywhere, in terms of what it does. There are estrogen receptors everywhere in the body. Name any organ, there are estrogen receptors. On the immune cells, B cells, T cells, mast cells, lymphocytes, every kind of cell. The macrophages and neutrophils — so every immune cell has estrogen receptors. The brain, the neurons, and of course, the immune cells of the brain like the microglia, the astroglial, all of those, the gut, the enterocytes, and then the enteric nervous system, the gut nervous system that is so amazing, that's why they call it the second brain, right? Every one of these things has estrogen receptors. The heart has estrogen receptors, the arteries, the endothelial everything has estrogen receptors, including the master clock in the brain, the timekeeper. And when you don't have enough estrogen, and that happens to women in menopause, because they obviously don't have enough, they go into — it starts to get off track, off kilter a little bit. So they are living a life of jet lag. And there's actually been some studies to show that the way that the cortisol — everyone knows there's a rhythm of cortisol, it should be high in the morning and then low at night. So in the morning it revs up your metabolism, it makes you hungry, it makes you a little insulin resistant, so that you will have sugar to feed your brain and your heart. And then at night the melatonin goes up, the cortisol goes down. They are flipped, right? They have high cortisol at night. And that's why they call themselves night owls. And then they get the night munchies. They are awake at night, they don't sleep well, they don't have the melatonin, which is such a potent antioxidant. And they don't get the melatonin in the gut either, which is so critical to gut health and the proper gut microbiome. So women with PCOS are living a life of jet lag. And now we know jet lag is associated with everything bad. More of everything that we said: More depression, mood disorders, sleep problems, sleep apnea, cancers, diabetes, metabolic disorders, everything. So there you have PCOS in a nutshell. It's pretty complex, because it involves every organ system, a multitude of symptoms, but fundamentally, it's about estrogen deficiency. Now, it was fine, that little bit that happened in ancient times was fine, the reason it's gotten so extreme now and it's increasing by leaps and bounds, is it's more than one thing. But one of the big things is endocrine disruptors.
I want to dive into that. It's amazing hearing you talk through all of that. It's really an elegant description of what is just a multi systems situation for people. And I think going back to something we said at the start of our conversation, that the field of medicine has gotten so niched and specialized, so it helps explain why women with PCOS often don't get the kind of treatment they need, because they are seeing all these individual specialists, each looking at a piece of this, but how you are describing this is really that these pieces all fit together and create issues throughout the woman's body, brain, all of that, which really means this condition I would think then lends itself well to more of an integrative approach of looking at what are the root pieces here. So we have got all this stuff, we have got insulin dysregulation, we have got reproductive system problems, we have got facial acne, we have got mental health issues, all of these things. We don't need 17 different specialists each looking at a piece. We need to look at the common roots of this right, which I think gets us probably into a discussion about things like the microbiome.
Absolutely. So what's happened is in utero, women are being exposed now to all kinds of endocrine disruptors. The one that's had the most research is BPA. Now BPA, is a terrible endocrine disruptor, and they have actually done recent studies that just came out a month ago, saying that the measurements were wrong. That they were measuring and coming out and saying it was so low, and that they were just measuring it wrong and that the levels were much higher than what they thought.
And these are chemicals and plastics and things like that that were exposed to.
Cash registers, receipts, the linings of cans, all the hard plastic like when you have a hard plastic water bottle. And if it says BPA free, it usually is BPS full. You know how they say there's no clean coal? There's no safe plastic. So we have to think of it. and it turns out it concentrates in the fetus. So the levels in the mother are much less than what's in the fetus. And so this actually reprograms, inappropriately, the estrogen receptors. So not only do you have in women with PCOS, they don't make estrogen as well. They don't receive it as well, the receptors. So I mentioned that the whole gut is filled with estrogen receptors, and we now know that when you don't have adequate estrogen, which women with PCOS are in an estrogen insufficient world, the gut alters. So we need to have proper estrogen. And in fact, the gut microbiome loves estrogen so much, it even has its own unique estrobolome to deal with estrogen, it is so critical. And the gut has its own production of estrogen, that's how men and children get it. It's so important to the gut, in what's called the Peyer's patches. They are little lymphoid nodules that are inside the gut. They actually make estrogen. But they don't make enough for women who don't have enough peripheral ovarian productions of estrogen. So right away, you get alteration of the gut microbiome.
Now this was hypothesized by a brilliant endocrine reproductive MD, PhD in Adelaide, South Australia. Dr. Kelton Tremellen. So I've been following the literature for years. And back in 2012, he put out a hypothesis article saying that women with PCOS have dysbiotic gut microbiomes. But he didn't prove it. He just looked at it and just figured it out. It makes sense. And he put in his article the most beautiful picture showing a leaky gut and how it links to the standard Western diet, which of course it's exacerbating. So you have a bad situation. And then it's on steroids because you have the conventional Western diet, which that in itself — You could take women who don't have PCOS, and give them terrible guts, because there are plenty of women who don't have PCOS who are obese and metabolically dysfunctional, and they are young. So we know they are doing gastric bypass surgery on teens now. So it's not like PCOS is the only way that you can get into trouble. It just is trouble magnified. So he just figured this out, he put out this beautiful hypothesis article. And then I kept looking in PubMed, because I'm a PubMed fanatic. And I kept looking and looking, and a few years went by. They had this email in the article. So I emailed him, I said, "Dear Professor Tremellen, are you ever going to prove your hypothesis? Because I believe it's true." He wrote me back and he said, "Let's do a study together." And I said, "Well, sure." I don't know. I'm not a researcher. I'm a clinician, but he's a researcher, he was published. We couldn't get any funding in Australia, and we actually started a study, and the Chinese beat us. They had really good funding. And then a couple more came out. But they had a beautiful study that was done in China that showed definitive, that women with PCOS have leaky guts, impaired gut barrier function, they have dysbiotic guts, they have higher lipopolysaccharides endotoxemia, which is horrible and you probably talked about that. And it's a huge problem. So now, it's worse than that because women with PCOS don't make enough estrogen.
Well, it turns out as I mentioned, every immune cell has estrogen receptors, so then every interface — the barriers of the body, when everything is right, has the most incredibly evolved immune systems to keep invaders at bay. And we use our own microbes to fight the others. There's little battles going on all the time. We just don't see them because we have our commensals that are actually making toxins that kill those that try to invade. The good guys fighting the bad guys, but everything has to be right and balanced because the commensals can turn on us too if we get them out of balance. So we have this beautiful balance, and every barrier of the body, and of course, the biggest one is the gut. But we have many other barriers, they are lined by these — I call them the sentries. They are keeping guard, and they are the mast cells. So they are the first responders.
The mast cells are the only immune cells that are pre packaged with all this crazy stuff like tumor necrosis factor alpha and histamine and protein S and everything, so it's all this stuff, it's right there to destroy the invader. So they are like grenades. They don't know who it is, they don't care. They could have toll-like receptors, they will figure it out later. But it's like "You are trying to get in, you don't belong, we are just going to kill you." So the mast cells explode. So it turns out that the trigger to cause exploding mast cells with releasing all this inflammatory content is much lower in women with PCOS. So a lower amount of stimulus will cause a bigger inflammatory response. And once the mast cells rupture, they put out what are called chemokine, that calls in the troops. So all the other macrophages, all the other immune cells of the body come rushing to create an inflammatory response.
So women with PCOS, when they have endotoxemia, when they have the toxins, the liposaccharides, these are the toxic products made by the wrong bacteria, usually gram-negatives, when this stuff comes right through the barrier, which should be intact, but it isn't, the immune cells lining the gut, all those immune cells — it doesn't take much, a lower threshold, poof, and you have chronic inflammation. So that's why women, now we understand that women with PCOS are chronically inflamed, because they have dysbiotic gut microbes, all the wrong guys growing in there, leaky gut, and a lower trigger to explode with our inflammation. And this inflammation, once it happens, it circulates through the body. And when you have the wrong gut microbiome, you don't make the right metabolic products like all the short chain fatty acids. And this links so heavily to the brain and to the liver. The liver, the metabolic powerhouse of the body. So women with PCOS have high rates of inflamed livers, which will ultimately lead to overproduction of glucose and fats. So when you have an inflamed liver, it just spews out fats and sugar that we call uncontrolled gluconeogenesis. It just keeps making sugar, that has nothing to do with what the body needs. And here you have inflammation, which breeds insulin resistance. So that's the perfect storm. You are producing all this sugar that the body doesn't need, and you can't get it into the cells because you are insulin resistant. And of course, that's the ticket to developing diabetes. That's why they have such high rates at such a young age, and all these pregnancy related complications. And then of course, with the brain, right, they get neuroinflammation, all the mood problems, and then that further exacerbates their circadian rhythm problems.
So it's really all of the things that we talk about with people in general, the things that can happen when you have a disrupted gut microbiome, this is really that issue on steroids for women with PCOS, because they are already physically metabolically in a state where it doesn't take much to start this whole chain of events. And so you take their predisposition with all of these pieces related to the PCOS and you combine it with what most people are walking around with, which is dysregulated guts, and boy, you just have this kind of free for all then that happens throughout the whole body.
Absolutely. And now we know — and I don't even have this in my book, it's such new information, maybe another book, but it's that when you have elevated fat in your diet, which is so typical, unhealthy fats, and then you also have the dysbiotic gut and you are making the lipopolysaccharides. That actually upregulates the production of this old but newly discovered system called the endocannabinoid system, and you have what we call increased tonality or increased production. So you have upregulation of the receptor called CB1 that's involved in this and then you have increased production of the two major endocannabinoids, the anandamide and the 2-AG. And when you have this upregulation of the endocannabinoid system, it's now been shown that the CB1 receptor is what causes the leaky gut. So we didn't really know exactly how this was happening, and it turns out, it's bi-directional. So when you have the upregulation of this endocannabinoid system, it is a system of lipid mediators, so these are fatty acids produced, the endocannabinoids come from Omega 6, from linoleic acid and then arachidonic acid.
Which we are very high in in the Western diet, Omega 6 fats.
That's where diet is so important for treating women with PCOS and everyone with dysbiotic gut, and because once you have this dysregulated endocannabinoid system, you have dysregulated appetite, and the fat cells become dysregulated. We know that we talk about the lipid type toxicity, lipotoxicity. So you have this influx of immune cells into the fat, creating inflammation in the fat, and you have upregulation of production of more fat cells. And all of this is regulated by the endocannabinoid system. And when you have more and more of this dysbiotic gut and more production of lipo polysaccharides from the gram-negative bacteria, you have more of this toxic fat being produced, and it's the visceral fat. That's why when they look at women with PCOS, 80% are overweight and obese, but 20% are what they call lean. The normal weight. Sometimes they are actually even underweight. But if they actually do evaluation of visceral fat, even the lean ones have high rates of visceral fat on the inside, do you know what we call them? It sounds so terrible. The skinny fats. Because they are metabolically dysfunctional and they are inflamed too. Obesity just adds another layer of difficulty and complexity to it. But even the Lean women with PCOS often have all the same array of problems, just sometimes slightly less, but they are often the most neglected group because they look fit, you can't see it. They often have terrible acne but they are very thin, and people just ignore them. The doctors ignore them, it's terrible.
I'm going to need to have you back for three more interviews to talk about several of these things. But in the time we have left, I want to give you an opportunity to share with the listeners some starting points. So you have just given this elegant description, such a helpful way of understanding what's going on in the body with this. The microbiome dysregulation is such a huge piece. What are some things that you recommend? Because I know you have this wonderful book about this? What are some starting points that you recommend for women? So they are listening in and they are going, "Okay, I get this. Now I get how all this is connected. I need to start working on my microbiome, I need to start addressing these things." What are a couple of tools that you have patients start with to kind of get this stuff moving in a better direction?
Yeah, I certainly don't want to leave on a low note. There is so much that we can do. It sounds so overwhelming, and it is, but we start with the very basics, and we can't really just start with one thing because it really is too complex. So we want to work on sleep. Sleep is so critical. Most of my patients will have sleep apnea studies, and then we have to get them on a sleep hygiene protocol. We have to get them to sleep. And I use a lot of melatonin, but not a high amount. A lot of people use too much. Just a little bit.
Most people use way too much.
Way too much. So we're good, in agreement. So it turns out that if you take just a tiny bit like a half a milligrams a few hours before bed, that will help to start lowering the cortisol and triggering the production of melatonin, and then if necessary, just a little bit, maybe one milligram, two milligrams a half hour before bed, maybe no more than three.
Don't go into your local CVS or Walgreens and get a 10 milligram bottle that's sitting there. Just because they make it doesn't mean it's the right thing.
No, no. And it's very interesting because the ovaries have melatonin receptors, and we can often help women just through sleep and giving this little bit of melatonin to help them to start ovulating again and getting them to be regular.
Even that's just such an important and elegant point really, because people say, "Oh sleep. Yeah, I know, I'm supposed to sleep." But what you are saying is actually that's a profoundly important thing. Sometimes we think about these complex multi-system conditions, and we think that the solutions to these must be extremely complex. And just by starting with sleep, what you are saying is actually something as simple, and that we would consider basic, as sleep has a profound impact. And I think that's important for people to understand.
When people look at what happens while you sleep — So we are diurnal. That means we are day creatures, and owls are night creatures, they are nocturnal. And so when people say "night owl", you know they are messed up, because this is embedded in our genes, we have clock genes. About a third of our genes are clock genes, and about 90% relate to clock genes, and those are immutable. We cannot change them. That's who we are. So we are diurnal. So we know that at night, we have an incredible increased blood flow to the brain. That's how the brain cleans itself. We have now discovered there's a lymphatic system of the brain, we have to get that the immune system is different at night, right? During the night, the gut is resting, you shouldn't be running to the bathroom to have poops in the middle of the night, that's a bad sign, and you shouldn't be running to the bathroom to urinate during the night. That's a bad sign. In fact, during the night, the bladder should be hardly filling.
And yet so many people, that's their norm. That's right.
That's such a clue that you have circadian rhythm dysfunction, you probably have sleep apnea. Sleep Apnea is often due, not so much as people have thought that it has to do with your tongue falling back. I mean, yes, that does that. But it's really central, it's really the brain. And so it's neuroinflammation involving the sleep centers and the breathing centers. So at night, your blood pressure should go down and your pulse should go down. All these things should happen at night. And if you are not sleeping, your body is basically not regenerating. Sleep is not passive. Sleep is active, but a very different type of active than during the day. And of course, that's when we burn fat. We burn fat and we have spikes of growth hormone, not to grow. Because that's another hormone that has sort of a weird name, because it helps us to build lean body mass. We want to build lean body mass. We have to sleep. And so we have to look at getting the blue light out, no television, computers, relaxation, a cool room. I sleep with an eye mask. I sleep with a fan on. We can get dawn simulators, we get bright light in the morning. By the way, bright light coming, no sunglasses, bright light coming in the eye triggers the production of serotonin, so we feel happy. And you don't need Prozac. Oh my gosh, that doesn't make you feel — that doesn't fix it. That's not getting to the root cause. But sunlight, so many people don't get out into the sun. That's why I love the sun coming in here. So the sunlight, and then what does melatonin come from? Serotonin. So that's why people go to the beach, they spend the day out in the sun on the sand. And then at night, they sleep like a baby, right? So we have to replicate that for women with PCOS. And if we can't get them out in the sun, we get light boxes. You can get 10,000 Lux, and you can do that, and you should do that in the morning for half an hour midday.
So great sleep hygiene is important, working on getting circadian rhythms working properly, maybe a little bit of melatonin if needed. That's a sleep piece. How about a couple things related to food?
That starts immediately. We started my practice with what we call the one month reset. Now, sometimes we call it detox, but sometimes the word detox rubs people the wrong way, so I kind of don't use it. But it is a detox in the sense that we are detoxing off of processed foods, sugars, crappy fats, the American western diet.
We are not getting all the toxins out of their body. We are going to help up regulate the liver function, though. We are going to help clean up the liver. Because the goal is — and I checked a lot of my patients with ultrasounds, that's the only real way to know if they have fatty liver, because I want to see it getting better. You can't monitor what you never measure. So I like to know, do they have fatty liver? And I want to know, do they have sleep apnea? I want to know these things. So with the diet, I recommend starting, if they are willing, vegan. Now the reason is that animal protein is a problem when you have a dysbiotic gut microbiome. You make this toxic product called TMAO, and that's not only a marker of a dysbiotic gut, which it is, it's also a cardiovascular toxin. And also, if you don't have the right microbiome in the mouth, you make these things called nitrosamines, which are carcinogens. So if possible. If people won't, then I say three ounces of animal. That's three little ounces. And by the way, that's good for the environment. Then I do high carb. Now, a lot of people are into low carb, so I'm like an anomaly here. I always like to repeat for people who say, "No! Carbs are evil." I'm the defender of carbs, because vegetables are carbs. So it turns out that the gut microbiome — and I can get you so many studies on this, it responds to polyphenols, the phytonutrients, they have a dance with the microbes, and the fiber. Fiber, fiber, fiber. That's what the prebiotic are, fibers. That's what the little bacteria need, and then they go down the little assembly line. So we got the prebiotics, the fiber and it changes everything. And when that happens, it calms down the endocannabinoid system, you can reestablish a good healthy gut microbiome. You can actually restore gut integrity, get rid of that leaky gut. And that is so critical.
The other thing is, we now know that everything is timed. Well, we are insulin sensitive and this is built into our genes, not mutable, in the morning. So our insulin sensitivity, meaning our receptivity, and our ability to use food properly is highest in the morning, there was a study out of Israel with women with PCOS. They had them eat two thirds of their calories for breakfast and one third for a late lunch and one bite for dinner. So almost all their calories were in their early part of the day, in just one month, their insulin and their testosterone fell by at least 50%. There's no drug that does that. So I tell my PCOS patients, as much as you can, try to eat a big breakfast. Now a lot of people say "I'm not hungry in the morning." That's a sure sign by the way, that's a sure sign that the endocannabinoid system which regulates appetite, the endocannabinoid anandamide should be very high in the morning, and then very low during the night. They have the opposite. So they get the middle of the night munchies and they are not hungry in the morning. So people say "I'm not hungry in the morning", I say, you are a human, you can think, you can do. So eat anyway, because it'll take maybe two months, but your body will adjust, you have to start eating in the morning.
So getting those patterns, just like the circadian rhythm with sleep, getting the eating patterns and insulin patterns, getting these patterns regulated in the way that it needs to be.
Because we know the gut microbiome has different phases itself, and it's designed to receive food in the day. And that's so interesting at night, when the melatonin is produced in the brain. It's also produced in the gut, and actually more quantity. And it turns out that there are certain species of bacteria in the gut microbes that swarm like insects when the melatonin comes out, and then they create different metabolic byproducts that have different effects. So everything is timed. You need to sleep so you get the melatonin in the gut, you need to give food to your microbes in the morning, because they are tired, and the other thing is you have to stop snacking. So I tell them — because we have what are called peripheral clocks. So I call it the backdoor way into regulating the circadian rhythm. That central clock is a little drifty. They feel like drifting. And you try to re-entrain it with the bright light. So the light and the sleep, the dark and the light, and that will help to get it back on track. And by eating at very regular times, you get your peripheral clocks, your gut microbiome has a clock and your liver has a clock. So you eat a breakfast — you never eat more than three times a day. I know the grazing thing that's out. So never more than three times a day, and try to make breakfast a big meal. front load, you know that old expression. Well, I don't know why cliches are always so brilliant but you know, "Eat breakfast like a king, lunch like a prince, and dinner like a pauper " And then if you have to have a little bit more dinner, make it early. Forks down by 7pm. And you need a fast from dinner to breakfast, not dinner to late lunch. Remember, you're insulin sensitive in the morning. And especially for women with PCOS who have dysregulation, they need to eat when their body is most insulin sensitive. So they have to eat in the morning. Yeah and if they have a social dinner, then they just have to eat it early and try not to break the rules too often. And what you can do as you get more advanced, is have a big breakfast, and either skip lunch, or do what I do actually, I work with a company L-Nutra that makes the ProLon, the fasting mimicking diet, which I use a lot with my PCOS because that's the next level, is to go into periodic fasting, either water fasting which is hard to do, or fasting mimicking diet, but they have these fast bars. And so a fast bar enables you to eat but not raise much of your blood sugar and your insulin. So you get food, but it's not a meal replacement. It's just a little bar, but it just helps you so that you don't eat more, and keeps your insulin, it gives you a little spike, not much. So it keeps it pretty level. And then have an early light dinner. Like a big salad, fiber, fiber, fiber, fiber. And so I push to try to go towards nine cups of vegetables a day. That's a goal. I know it's hard. And then I also have another expression: Don't be afraid of fruit. Fruit isn't what gives people diabetes. It's chemicals, it's circadian rhythm dysfunction, it's night eating. It's a lot of stuff, it's all the processed food, but it isn't because they ate an apple. Oh my gosh, there's wonderful polyphenols in this fruit, and the prebiotics. So I travel around the world when I'm speaking, and I was in Oman last year, and I took the tour. They lived on their dates.
I lived in Oman for a while when I was young. That's right. Yeah, dates, dates, dates, dates.
They weren't all diabetics now. And they said "Dates, don't eat dates." Dates are wonderful. They have beautiful fiber. All these wonderful micronutrients. But like everything, it's great if you eat it with walnuts, right? Because you are getting healthy fats. So the other thing is Omega 3, Omega 3, Omega 3. We touched on Omega 6. Omega 6 is not evil, right? So it's not like down with Omega 6. If you don't have enough Omega 6, you can't make your endocannabinoids. And they are not evil either. Actually when things are balanced, they are wonderful. Of course, they are part of our body's lipid signaling system that they are now calling the Endocannabinodome, because there's hundreds of these lipid signaling agents. But if you have only Omega 6, you don't make the balancing, the other ones the resolvins that help resolve inflammation and the Omega 3. These lipid mediators come from our cell membranes. It's so amazing, right? And that's where phosphatidylcholine and phosphatidylinositol are, and we give a lot of inositol in women with PCOS. And then, of course, phosphatidylcholine is so popular in our functional medicine world, and the people don't know why. Omega 3's balance out. And actually, if you have enough Omega 3, it calms down the production of the endocannabinoids.
So what are some foods that you recommend for people to include then to boost their Omega 3 levels?
Well, I used to recommend a lot of fish, but now it's like uh-oh because of the mercury. I'm using more supplements now. So krill actually is incredibly beneficial, but regular high quality Omega 3 from sardines and such are also very beneficial. So I do recommend a lot of these supplements, and you do get some from the ALA like flaxseed, but our conversion is small. But I do love phytoestrogens by the way. There's tremendous data on organic soy, so I have to defend the defenseless like carbs. And then soy, soy that's been processed and has GMO is terrible, right? And so it's the evil twin. But real whole organic soy is a fertility food. There's actually published studies that it improves fertility, and it also helps to regulate the endocannabinoid system. And so it's actually very beneficial. If you look at the Blue Zones like from Okinawa, that's the blue zone. Their carb intake, 80%, 85%, so when I say mine, I recommend 70% carbs and people roll their eyes, like "70%". No, look, the Okinawans were the most long-lived people.
And probably with organic soy and things in their diet too.
They had a lot of soy. That's right. A lot of soy. And then you look at the ones from Sardinia, that's another blue zone. They had very high Omega 3, but a lot of their Omega 3 came from dairy from grass-fed cows and sheep, which is not here. That's why I exclude dairy. Dairy in this world for women with PCOS, I say no dairy, because it increases IGF1 which then increases insulin and vice versa and then it increases testosterone production, and it's inflammatory. So we basically want to eat — and by the way I defend root vegetables, rutabagas and parsnips and yams and everything under the ground, garlic onions, beets are great. And they increase nitric oxide. So we love nitric oxide. Women with PCOS have low levels of nitric oxide, a gas that helps everything to work right. It's an antioxidant, it makes the arteries healthy, the brain healthy. So lots of vegetables, tones of vegetables, aim for nine cups, no more than three meals a day, heavy load for breakfast, stop eating early by 7pm, 13 hour fast, and you can do more than 13 hours but the return on investment gets less and less, so why kill yourself with low return on investment?
Have a good fasting period from an early dinner to breakfast.
And try to eat breakfast by no later than 10am, preferably within two hours of getting up. And then of course, we add in all the other things: Stress reductions and exercises and avoidance of — we go through how do you avoid BPA and phthalates and flame retardants and all the other chemicals. So we try to put it all together, and occasionally for women, if they don't respond, I give them some bioidentical estradiol because I know they are low in estrogen, but that's not what I jump to. And most women, the vast majority, by changing their diet, changing their microbiome, getting their circadian rhythm back on track, working with sleep, stress, movement, light, we get them ovulating. They restore their fertility, their lives. And you know what? Then suddenly, being PCOS — and I emphasize this, in ancient times, they were the women who dominated their tribes because they had that little bit of extra testosterone. By the way, they have done studies on women who have been gold medalists in the Olympics. They have low level PCOS. Yes, the competitive edge. They have a little extra testosterone, a little extra muscle, a little extra drive. They are brave, they are fearless. They are powerful women. Yes. So we want to get back to our roots. We can do it.
Such a hopeful and helpful message, because so many of these women just feel like they have been grasping for what to do to really impact this. So many amazing things you have shared, definitely going to have you back on the show because there were several things that I now logged in my mind, like we need to do a whole show on that. So this was amazing. Thank you so much for being here. Just a wealth of really valuable information. I can't thank you enough.
And thanks to all of you for joining us for today's episode of The Better Biome Podcast. Tune in next week to continue with us as we journey through the universe within.