Ep. 221 Part 1- An Integrative Approach to PCOS and Menstrual Irregularities with Dr. Felice Gersh

Cynthia Thurlow: Welcome to Everyday Wellness Podcast. I’m your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent, is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.

Today, I had the distinct honor of connecting with Dr. Felice Gersh. She’s a multi-award-winning physician with a dual-board certifications in OB-GYN and integrative medicine. I had the honor of meeting her in person in 2019 and I can assure you, this is the very first of two collaborations in terms of podcasting. Today, we dove deep into PCOS or polycystic ovarian syndrome. We spoke about how this is the most common female endocrine disorder and the leading cause of infertility in women. We spoke at great length about the basis for PCOS, how we are genetically predisposed in many instances. It is a syndrome of inflammation, imbalanced hormones, and insulin resistance. We spoke about symptoms, how this can predispose you to autoimmunity, as well as endometrial cancer. 

We spoke about estrogen and the role in PCOS in particular, how this has a net impact systemically on our ovaries, pancreas, liver, intestines, it’s a modulation of inflammation, how shift workers struggle with circadian rhythm disruption, as well as women with PCOS, lifestyle changes that we can do to augment as well as supplements and medication. Dr. Gersh is an incredible, incredible resource. I am so very grateful to be able to share this information. I’ve had so many younger women asking for a good podcast on PCOS. But stay tuned. Dr. Gersh will be returning this fall and we will speak at length about perimenopause and menopause. I hope you will enjoy this podcast as much as I did recording it. 

Well, Dr. Gersh, it’s such a pleasure to reconnect with you. I actually was in Florida at the same time you were. You spoke at a forum and I spoke in a breakout session, and I missed having an opportunity to see you speak, because we spoke at the same time. I kept saying, “How can this happen? [laughs] So, welcome. It’s so nice to have you on. 

Felice Gersh: Well, the universe put us back together. Yay. 

Cynthia Thurlow: Exactly, exactly. Now, I would love for you to share with the listeners. Did you always know that you wanted to be an OB-GYN? Was that the trajectory of your young adulthood that that was the direction you anticipated going in or was this just a random occurrence? Because it looks like your entire career has really been devoted to the care of women. And so, I know it’ll be an invaluable conversation. For listeners to know, this is the first of two episodes. Dr. Gersh has very graciously agreed to come back because there were so much to discuss that we could not do it in one hour segment.

Felice Gersh: Well, no. 

[laughter] 

Felice Gersh: Actually, it was not I was born knowing my destiny or anything like that. But I did come from a family that gave a very limited menu of career opportunities and I never questioned it as it turns out. And so, growing up it was always understood that I would go into a career. My mom was an attorney, so was my dad and we just had a lot of expectations that women are going to do whatever they want to do. But I only had three choices that I understood. One was to be a lawyer like my parents, another was to be a teacher, and the third was to be a doctor. Well, okay, so, okay, get it, lawyer, doctor, teacher, which one am I best at? I said, “Well, I’m good in science and everything was supposed to be serving people and helping.” And so, I picked doctoring. And so, I didn’t want to just exclusively learn about science, I really had interest in many things.

In college, I actually majored in history and dabbled in history across the whole history of mankind and did a lot of art history. But then I had to take all the prerequisites, of course. I had all these other science courses that I had on the side. And then I got into medical school and my parents went away for two years. When I spoke to these really hotshots like, well, renowned hundreds and hundreds of published articles on PubMed and everything else, all they told me was, “You’re not trying to get pregnant. So, just go on birth control pills, just go on birth control pills.” It’s like, but something is wrong with me. And that was really the spark that set me on my journey is like, “Okay, so many people.” We always make jokes about psychiatrists, but we won’t go there. It’s either something in our family, something in ourselves that triggers us to learn more, to want to understand. Trying to figure out what was wrong with me have made me want to go into women’s health. 

And then when I did my rotation in medical school, in OB-GYN and I was doing the labor and delivery rotation, and I was delivering babies, and I saw how sick many of these women. This was a county hospital. They were very sick and I saw how much medicine you needed to know. You know what, and also, I became an adrenaline rush addict. I didn’t realize that that was in me. But just the life and death scenarios that presented themselves in a labor and delivery scenario and I wanted to do that. I said, “You have to know everything.” To do obstetrics properly, you need to know about medicine, you need to know surgery, and you have all of this– When you see ER, because you’ve been in there, where you have truly immediate life and death situations, where you can save lives two at a time. 

But also, what I liked about OB-GYN was the continuum of care. Because you not only just did like a surgeon or a trauma surgeon, where you just had that one intervention, and then next, next, next. No, you could create lifelong relationships with the women, because they would come to you. And that was the time when it was being debated, “Are women going to go to an OB-GYN just for pelvic care or is the woman going to use the OB-GYN as their primary care physician?” And I took that position, because I loved medicine and learning how to deal with a lot of things. So, I wanted to do more than just pelvic stuff. 

And I also saw the context that everything is linked to everything that when women have– Before it was even discussed, because I go way back that the menstrual cycle meant something to the woman’s health status. It wasn’t just, “Oh, well, I guess, you can’t get pregnant easily.” No, it meant, she’s not healthy when she has a menstrual cycle dysfunction. I guess, I saw everything in that field and that’s where I am today. Then I’ve made many twists and turns since I began as we all evolve and led me to wanting to be with you here today to really help educate women about what it takes to be a healthy woman.

Cynthia Thurlow: Yeah. Well, I’m so very grateful that you had that trajectory of your career and has gotten you to where you are today. I think there are a couple things. First of all, as a former ER nurse in Inner City, Baltimore, we were terrified of pregnant women. We did everything we could to immediately get them to the OB floor, because we were terrified of women at that life stage, because we never liked having women deliver in ER bathrooms and that happened quite a bit.

Felice Gersh: Yeah.

Cynthia Thurlow: We would say, ”No one goes to the bathroom.” If you’re a pregnant woman, you’re not allowed to go to bathroom.

Felice Gersh: [laughs] 

Cynthia Thurlow: You have to be with a healthcare professional in the bathroom. Number two, how many women listening including myself experienced menstrual cycle irregularities and were prescribed a pill? I remember being 16 years old. [crosstalk] Exactly. I was 16 years old. I probably had very mild PCOS, which we’re going to talk about today. I didn’t fit the typical phenotype of someone with PCOS. But my cycles were so irregular and my GYN very kindly said, “We have something that can fix this problem.” And I then remained on oral contraceptives until I got married. I thought in my brain, even as a nurse practitioner didn’t even think about what the net impact was. But when we talk about oral contraceptives, oftentimes, masking those menstrual irregularities, it is a huge issue. In fact, I feel with good intent they are prescribed and I always say, “Listen, there’s no judgement when women are looking for reliable contraception that oftentimes can be a viable option. But we don’t realize what the net impact is, it’s masking whatever that irregularity is.” And so, you are recognized expert on PCOS or polycystic ovarian syndrome.

When I was reading your book, which is my favorite book about PCOS to recommend PCOS SOS is that book. One of the things that I found really startling is that you mentioned that PCOS is the most common female endocrine disorder and I thought to myself, “Gosh,” in my mind, I’m thinking diabetes. That’s usually what I think about that it just diabetes, and insulin resistance, and PCOS, all go together. But that was such a profound sentence that I read. I thought I have to really take that in. From your perspective, in terms of looking at PCOS as a disorder and it’s a disorder related to menstrual irregularities, but it’s so much more than that. As I dove into your book, which I mentioned I reread last week, it really reminded me why it’s so important to have these conversations. Because PCOS is not benign. And I think many of us think of it as being this benign entity and it really isn’t.

Felice Gersh: No, and it’s really interesting how just in the last few weeks, several articles have been published that have been out there on things that those of us in the medical field see all the time like med page and Medscape and they always putting out some of the newest articles. They’re like, “Oh, PCOS is pregnancy is associated with heart failure, more heart dysfunction. Or, women with PCOS are more likely to have hypertension when they get older.” Of course, this is like, “Duh. There’s so many things that they discovered.” It’s like, “Excuse me, we actually knew this before. You didn’t discover it.” And PCOS is about everything involving female health. Because we were chatting about this before that the menstrual cycle and you alluded to this just a few moments ago is really a vital sign of female health status. Just like you go into the ER and you say, “What’s the blood pressure?” “Oh, no, it’s 60 over 30. That’s a big problem. Or, it’s 180 over 120. That’s another big problem.” So, it’s a vital sign. 

Instead of recognizing that when it’s all messed up, it’s irregular, it’s incredibly heavy, it’s prolonged, it’s terribly painful or you get horrible PMS. That is a giant red flag that this female’s body is in trouble, something is wrong. And it’s all smoking mirrors when you give oral contraceptives. It drives me crazy and so, you, too. When the doctor, like you said, well-meaning says, “This is going to regulate your cycles.” You’re not regulating, you’re covering up. So, you’re taking the ovaries offline, you’re completely shutting them down and replacing the human beautiful natural hormones and rhythms, which you deal with intermittent fasting. If we know that, it’s not just what you do. It’s when you do it. It’s not just that you have some kind of hormones. It’s when they come out in pulses, and the rhythms, and the beautiful lunar cycle, and there’s even circadian cycles of hormones. None of that happens when you’re on a birth control pill. 

You’re changing the entire physiologic dynamic of the female. And of course, there are repercussions. They’re just not immediate in most cases occasionally and they’re always subtle. They’re long term. When people are exposed to endocrine disruptors, chemicals in our world, they don’t fall over dead. If you have a lot of chemicals that are inappropriate, that’s everybody has a lot. But BPA, which has the most research in PCOS, that’s why I brought that up. It’s ubiquitous, it’s everywhere, endocrine disruptor, it doesn’t just kill you immediately, but it can have all kinds of profound long-term effects. And that’s what we’re looking at. We live in a world where we can only associate causal relationships when they happen immediately. But no, there are causal relationships that can happen even decades.

For example, they have now found out that young women back in the day when DDT was sprayed all over for mosquito control on beaches, and they would just go around and spray DDT, and young girls like 12, 13 years old were literally sprayed with DDT, those women have substantially increased risk of developing breast cancer in their 40s. We wonder, “Why are all these young women, suddenly, why do we have a seven-fold increase in premenopausal breast cancer?” It’s because of chemicals that they may have been exposed to many years earlier. We know that in utero exposure to various toxic and chemicals can increase childhood leukemia and that could be years later. The bottom line is that birth control pills and we could talk forever on that. Maybe someday we’ll do another just on what it means to have contraceptives, all the different types out there. Because it’s really a huge, important deal that every woman know about. 

But birth control pills are not human hormones. They don’t regulate anything. They take down your own hormones, they don’t fix you, and they have a proinflammatory propensity. That’s really important for women with PCOS to know. Women with PCOS live in bodies that are metabolically unhealthy. They’re not just reproductively challenged. They are truly metabolically unhealthy. If you say, “Well, what the heck is metabolism anyway?” People throw the word metabolism around all the time. So, what are you talking about? Metabolism is the creation, utilization, storage of energy. What’s the difference between you and a person who isn’t alive? Well, you make energy. That’s why everyone has seen TV shows where they have the EKG, and you see the heartbeat, and then, “Uh-oh, it’s flatlining.” That means the heart is no longer creating energy. That’s an electrical signal. The same thing with the brain. “Uh-oh, flatlining.” That mean your brain dead. The brain is not creating energy. So, you need energy in order to function.

Old people, they’re sitting on the bench in a park is that because they love benches? No, it’s because they don’t have the energy. They would love to be running around like the kids out there on the field, but they’re tired. They don’t have the ability to make that kind of energy. So, metabolism is like a critical thing and women with PCOS have an altered not healthy metabolism. They don’t make energy well. And that’s for every organ system in their body, because estrogen is critical for the creation of energy. And it has many, many functions. But that’s a huge one, because we have these little energy factories in every cell called mitochondria. They create the energy by burning our energy source aka food. Glucose, and fatty acids which turn like into ketones and so on. But in order for that to happen, you have to have proper estrogen in the form of estradiol, the estrogen made by the ovary, that is not what is in a birth control pill. When you don’t have proper estrogen, you also don’t have proper functioning of your immune system because estrogen holds the key to immune function, which is critical for survival and very involved in reproduction. Because we don’t want to kill with our immune cells our little fetus, and we don’t want to kill the sperm. It’s an amazing thing. 

Estrogen regulates the immune system. Now, that means it works the switch that turns on and turns off inflammation response based on what the body needs. If you have an infection like COVID, you want instantly the inflammatory process to be turned on, but then you want resolution, which some people don’t get. They get the cytokine storm? Well, estrogen, which by the way, there have now been reports, but finally, I knew this from the get go that women who have proper estrogen are going to do better. That’s why women statistically do better among other reasons. So, the bottom line is that when you have proper estrogen, the immune system is regulated, you make proper energy to all the organs work properly, and then it goes on and on, which we can touch on a lot of these other things. But when you don’t have the estrogen like women with PCOS and you have immune cell dysfunction, you are going to be in a proinflammatory state. Because by default, you go into that proinflammatory state. So, you are more prone to blood clots.

Birth control pills. Most people have heard of this. Birth control pills increase blood clots. Now, why is that? Is that an isolated fact that birth control pills have this single effect on platelets that create blood clotting? No, it’s because they initiate a low-level state of inflammation by decreasing the production of nitric oxide, anti-inflammatory, antioxidant gas that is required to maintain proper immune function in a whole different set of ways. And also, it activates the innate immune cells like the attack cells to be in a proinflammatory state because birth control pills have only one effect on one estrogen receptor, whereas estrogen from the ovary has a balanced effect. So, you get stuck in that proinflammatory state? Well, now, it’s additive. And there are published studies to show this that when you take birth control pills and you have PCOS, you are even more proinflammatory and increases even more the risk of blood clots.     We know that we don’t give birth control pills to women who have uncontrolled high blood pressure. We don’t give them to women who just had a heart attack. If they’re so great, why don’t we say everyone has a heart attack? Let’s give you birth control pills. Of course, that never happens. We know that there are women who’ve had blood clots, we don’t give them birth control pills. 

To me, women with PCOS should be in that category of high risk like women who are elderly, we don’t give women who are smokers. There’re so many of these, don’t give kind of categories for birth control pills. To me, women with PCOS actually fit into that group. So, it’s really important. I know there’s a lot of time on birth control pills, but it’s important because that’s the mainstay treatment of PCOS like for you, for me, because I’m like you. I’m like the smaller percentage of PCOS women who were not the 80%, who are overweight and substantially obese. But don’t underestimate the seriousness of the so-called lean PCOS because they can suffer and develop all the same complications. They just have a little bit of advantage of not carrying as much adipose tissue, but they have a lot of disadvantages too, because they often have poor body composition and lower muscle mass. So, don’t think that they’re so great off. They have a lot of potential risk, especially as they get older into the menopause years of having a lot of cardiovascular problems and other problems.

PCOS is important for every woman to understand, even if she doesn’t have PCOS. But like you said, it’s such a prevalent condition. There’s no one actually keeping records. No one is actually out there trying to collect data. The only data we actually have is from insurance billing data. That’s really, we have the data and a lot of times doctors code it wrong. They’ll put down a symptom or they’ve had so many published reports about women go to 11 doctors before they even make the diagnosis, which is weird, because it’s obvious in most cases, I think. But the bottom line is that we don’t know the exact incidence, but we know it’s at least 10% of all reproductive aged women. That’s a lot. It may be at least 25% have their– it’s a spectrum, because it’s a syndrome. That’s why there’s different severity, somewhat different manifestations, and so on. But every one of you listening either has PCOS or know someone with PCOS, and the information that goes into treating PCOS properly, the lifestyle part, which is the key part really is really relevant to everyone because it’s really foundational lifestyle medicine.

And women with PCOS just have a more severity status of everything that we talk about, but everyone has toxins in them. Everyone has to live with circadian rhythm challenges. Everyone has to live with dietary challenges, stress challenges, sleep challenges. So, everyone, regardless of whether you have a full-blown diagnosis of PCOS have some degree of challenges that all women with PCOS have on steroids. So, it’s good to really understand all of this.

Cynthia Thurlow: Well, and I think it’s really relevant because how many of us weren’t diagnosed with PCOS until we tried to get pregnant. For myself, I had a really excellent GYN and I was temping. I was doing all the right things. I was temping, and I kept bringing in my charts, and I said, “I think I have a luteal phase defect” and we can describe what that is. Because it was evident that I probably had low progesterone. Anyway, a whole bunch of things. 

Felice Gersh: Mm, of course. 

Cynthia Thurlow: My GYN very appropriately said, “We need to refer you to reproductive endocrinology,” went to see the reproductive endocrinologist, he confirmed that I indeed likely had this thin phenotype of PCOS. I ended up doing Clomid and IUI to get pregnant with both my children. For me, it was very humbling because I had assumed I was very healthy and all of a sudden, I’m looking at my husband and I’m thinking like, “If we’re really healthy and we’re having trouble getting pregnant, and the more I talk to patients and friends, I’ve realized there’s a whole generation of us that are struggling with infertility.” For many people, they’re told it’s male factor, they’re told they don’t understand why they’re infertile. For many of us, it was because of the PCOS piece. And once that was addressed, then I was able to ovulate and get pregnant. But I think it’s important for people just to understand that the leading cause of infertility is undiagnosed or diagnosed PCOS.

Felice Gersh: Absolutely.

Cynthia Thurlow:  And so, it is a huge issue. My hope is that through this podcast we can help build awareness and know you’re doing wonderful work in this area as well. What are some of the common symptoms? Some of them ones in your book were the traditionals and then there were a couple that were surprising and I’ll give an example to listeners. I had been told for years, I had great teeth. But I was told there’s my gums, very inflamed gums. I’d gingivitis. I even got referred to a periodontist. And thankfully, the periodontist put the brakes on and said, “Listen, I think it’s because you’re on oral contraceptives. I think when you stop oral contraceptives, your gums will get better” and sure enough they did. But gingivitis, just inflammation of the gums can be a sign of PCOS. What are some of the more common ones that people may recognize?

Felice Gersh: Well, I’m just going to backtrack for one second just for people out there who are like, “What the heck is PCOS anyways?

Cynthia Thurlow: [laughs] 

Felice Gersh: It’s just in terms of like manifestations. Because we’re talking about symptoms, because a lot of what PCOS is, is diagnosed based on symptoms. You get a committee of doctors, they get together, and they define what is the name of the condition. That’s another battle that’s ongoing. What are the criteria for getting that label? To get the label of you have PCOS, you need according to this committee, I don’t totally agree there were outliers like me and many others, The Androgen Excess and PCOS Society, who disagreed that you need to the following three though, officially. You need to have irregular cycles of any kind of irregularity to any degree. You need to have elevated androgens. Androgens are like the male type hormones. But women have them just in much smaller amounts and that includes testosterone and that is produced by both the adrenal and the ovaries. 50-50 in a normal reproductive age women from each of those organs and DHEAS, which comes solely only from the adrenal and/or manifestations like you have to shave every day, which is unfortunate and common. And now, they’ve included recalcitrant cystic acne, the hormonal acne on the jawline, that type of thing, and androgenic alopecia. So, it’s like the female version of male pattern baldness.

The last criteria is PCOS ovaries on ultrasound. I want to just mention that in young teen that’s within say of just five years of onset of their menarche, their first period, this is not a useful diagnostic tool, because part of becoming reproductive and maturing is having what look like PCOS-type ovaries, you can call it the ovaries are still on their training wheels and they can look like that. You don’t want to over diagnose and that’s another issue. The young teenage years is a little harder, because, as you know, 90%, well, now you know, 90% of teens have acne, which is a whole other topic because of gut dysbiosis, and inflammation, and diet, lifestyle, and everything. But since 90% of girls have acne and young girls will have PCOS ovaries, even if they’re not going to develop PCOS, you got to be careful about the diagnosis in that age group and you have to do other things. We won’t talk about the very young teens right now. But just be careful about not doing those kinds of things and making those judgments on those girls like a 14-year-old. But you could say, PCOS tendency, something like that. So, those are the criteria you need two of three.

Now, once you understand that PCOS is by its foundational nature, a woman functioning in a deficient state, an insufficient state of estradiol, the estrogen from the ovary and then you understand that estradiol has a role, I call it gluing together, reproductive functions and all metabolic functions. Every organ system in the body has estrogen receptors. And there’re different estrogen receptors and they have a predominance of one type or another in different organs. That’s why you need estradiol, the one that has the balanced effect on the different estrogen receptors. In medicine, they’re trying to create what they call designer estrogens that work on only one of the receptors, but you’re naturally then creating an imbalance to try to get an effect and you’re always going to end up in trouble, if possible, unless you’re short-term treating some specific condition like we’ll say breast cancer. That’s a whole unique situation where everything is altered. But if you’re just treating to have a healthy body in a woman, then you don’t want to try to treat only one estrogen receptor.

But recognizing that there are these tremendous complexities of different estrogen receptors, different amounts in different organs, but every organ has an involvement, a huge involvement with estrogen. And hormones which estrogen is a hormone and estrogens are a family of hormones. And estradiol is the estrogen made by the ovary that we have different interactions between the receptors. They can up and down regulate each other. There are even receptors in different organs like the heart that work with estrogen as a cofactor. We call them estrogen-related receptors, where estrogen isn’t even what’s binding to the receptor, but it needs to be there like a coenzyme in order for that receptor to bind properly with what it is supposed to bind with and then create. We even have receptors especially in the brain and the heart that bind to certain specific estrogen metabolites that are made when estrogen goes through the liver and gets transformed that we call biotransformation. That’s how unbelievable estrogen is. 

We even have a specific gut microbiome dedicated to dealing with estrogen called the estrobolome. I cannot underestimate the critical importance that estrogen plays in the female body. And women with PCOS have ovaries and this is 80% of women with PCOS. There’s also a version that predominantly adrenal, which has similar manifestations, but somewhat different etiology. We like to talk about the mainstream, which I focus on in the book, which is at least 80% to 85% of all PCOS women fit into the ovarian etiology. They don’t make enough estradiol and now, we know that due to exposures of the fetus in utero to endocrine disruptors like BPA, that’s what’s had the most research is phenol A which is everywhere. It’s what’s in hard plastics, can liners, cash register receipts, a lot of dental appliances, and so on. It actually is a huge endocrine disruptor in a multitude of ways and it can actually alter the way the endocrine system develops in terms of the receptors, so that you have receptors that don’t work properly. It doesn’t matter if you have a hormone, but if it can’t work on the receptor, you’re not going to get the desired effect. 

Basically, the thing to remember is that women with PCOS have a problem with the production of estrogen in the form of estradiols in their ovaries, the receptors are not working optimally. And so, basically, they have an insufficient amount of estrogen in the form of estradiol working throughout their body and every organ system of the body needs it. Basically, all the microbiomes, so, we have now this incredible new understanding that we are just one part of who we are that we have these collections of trillions of microbes that live everywhere and the biggest collection is the gut microbiome. But we have other microbiomes, vaginal skin, every organ system. I was taught incorrectly, I bet you were, too, even you were taught later that everything in the body was sterile. It’s just the thought of that. I don’t know why I believed it at the time. Now, I question everything. But is there a stop sign at the cervix that says, “Bacteria do not enter?”

Cynthia Thurlow: [laughs] 

Felice Gersh: They enter. How else do you get PID, like gonorrhea and Chlamydia and– They could go up. You have microbiomes of the placenta, the uterus, the tubes, the ovaries, the brain unit, everything has different degrees of bacteria, different types, and so, does the mouth, the oral cavity. Getting back to your gingivitis which, by the way, I’m like you. And I also had gingivitis and I kept wondering, “What is happening? Why do my gums bleed? I’m doing everything right.” It’s because the mouth microbiome, it turns out that estrogen is key to maintaining the microbiomes of everything. That’s one of the reasons why women with PCOS can get this recalcitrant cystic acne and they’ve shown this. The microbiome of the skin is different. It doesn’t have the protective, what we call the commensals, that actually–

There’s a war going on. Everywhere in your body with good guys, with the bacteria, the microbes are fighting off the bad guys. When we don’t have enough good guys, guess who wins? The bad guys. And then we have colonization with pathogenic bacteria that actually create harm and that’s true for women with PCOS, unfortunately, because estrogen works with the immune system as I’ve mentioned and it works with creating the proper secretion of sebum, and in the vagina, glycogen, which is the food source. It’s like a starch that the vaginal lining cells like to feed the good lactobacillus, which keeps the vagina in an acid state, so, you don’t have overgrowth of Gardnerella and these other anaerobes, and then you have the BV, and you have the yeast infections, and you don’t have the right bacteria to help you fight off these things. So, that happens in the mouth as well. 

They’ve now a few studies– I’m so happy when anyone does any studies on PCOS, because it’s really a talk about insufficiencies. We have tremendous research insufficiencies with PCOS, even though like you said, it’s the most common endocrine disorder of reproductive women and it’s so minimally researched and funded. But we now have data that shows that, duh, it’s another duh, of course, because every microbiome is altered, the microbiome of the mouth. And so, you have the good guys in the mouth, the commensals, the helpful bacteria that are fighting off the bad bacteria. They’re not enough of them. So, the bad bacteria take over, and then they start creating inflammation, and inflammation causes, of course, whenever you hear ‘it is’ that means inflammation. Like, appendicitis, arthritis, gingivitis. It means that you have inflammation in your mouth, in your gums. That’s because you don’t have the right mouth microbiome.

There’s research now. I recommend a probiotic toothpaste. There’s not enough research, but there is some data to support probiotics for a lot of different things, but it’s in its infancy. But helping to get the right microbiome established and that means don’t use poisonous stuff in your mouth on a regular basis, which is a problem. Because back in the day, they had certain types of mouthwashes that they used as little saying like, “Kills germs on contact.” Well, duh, that’s a problem because not all of those so-called germs are bad dudes, a lot of them are the good dudes. Like antibiotics, you’re not just killing bad ones, you’re killing good ones. That’s another thing that of course happens a lot is a lot of antibiotic use. And so, we have problems in many people with gingivitis. But women with PCOS, that’s why I say, it’s everyone else, only worse. [laughs] They just have the worst case scenarios of so many different things like women with PCOS. 

The first research came out of China that they have gut dysbiosis. They have the wrong microbiome of their gut, which results in impaired gut barrier known as leaky gut, which then the toxins that are produced by the wrong microbes in the gut, leak out between the cells of the lining of the gut into the body proper, where 70 plus percent of all the immune cells of the body reside, and those immune cells of women with PCOS have a lower threshold to creating inflammation. This actually was published out of research in the University of Indiana back in 1998. A friend of mine, who is a researcher, one of the few in PCOS found  that women with PCOS, their immune cells take less to create a very big inflammatory response, like, putting out all those inflammatory cytokines. You have the worst of all worlds. You have the impaired gut barrier, the leaky gut, the endotoxemia, the toxins coming in, and immune cells that have a lower threshold to creating more substantial inflammation. And so, there you have it. It’s like a perpetuation. 

You have multifactorial things happening in women with PCOS creating this chronic state of low-grade inflammation, which drives problems in their vascular system, in their heart, in their brain, in their joints. That’s why the multitude of symptoms. And that’s why women, sometimes with PCOS will have more of a dominant, something like gingivitis or they can have palpitations, they can have mood disorders, which are so much more prevalent. Anxiety, and depression, and ADHD because the brain has inflammation and lowered energy production. That’s the worst of all worlds. And so, we need to help. And now, they have the new articles. I’ve mentioned that women who are pregnant with PCOS are more prone to developing heart failure. Well, that’s another for me a big duh, because it’s so fascinating. 

Women have different hearts than men. This is not even recognized by cardiologists, because of pregnancy. Pregnancy changes everything. When a woman is pregnant, what happens to her blood volume? It doubles. That means her heart has to pump twice as much blood around. That means that heart has to do double duty work. What is unique about a female heart versus a male heart is the number of mitochondria, the capability of creating energy. In a female heart, it has to be dramatically higher than in a male heart. Well, as I told you at the beginning, what is critical to the creation of energy? It’s estrogen working in the mitochondria at all different levels, both through the creation to what they call the electron transport chain and also working with a very important enzyme called superoxide dismutase. Because when you have the creation of energy, you create byproducts that are toxic and those have to be eliminated. One of those is called superoxide. It’s two oxygens together poison as can be, but it cannot get out of the mitochondria. It’s stuck in the mitochondria. 

If you can’t do something to get rid of it, to change it into something less toxic, then it’s going to kill that mitochondria. That will happen if you have a deficiency of estrogen, because estrogen works to keep the enzyme that works to take that toxic toxic superoxide and converts into hydrogen peroxide. Now, you’ll think hydrogen peroxide, that’s poison, too. But hydrogen peroxide can diffuse out of the mitochondria and then there are other enzyme systems that are also involved that’s converted to harmless water. You have to have estrogen, so, you don’t have the killing off of the mitochondria that they work properly. Well, women with PCOS don’t have proper functioning of the receptors and so on. They’re going to have problems with creating energy in their heart during pregnancy, where there is a double energy need, the heart has to pump twice the amount of blood around the body. So, it can fail. 

And in fact, women when they have energy deficient hearts on echocardiogram, it shows up in a very unique way called mild diastolic dysfunction, which is an energy deficient heart that’s stiffer and it doesn’t relax properly. And you know what the cardiologists typically do when they see it? They say, “Oh, that’s typical.” We see that all the time in women. It’s like, “Excuse me, that’s a sign. It’s like the menstrual cycle is messed up” and the solution is, “Well, just give them birth control pills.” We see that all the time. It’s a problem, guys. Doctors out there, it’s a problem, when you have an energy deficient heart, when you have menstrual cycle irregularities. The cardiologists don’t recognize it. So, at least, somebody now is bringing that up and they’re publishing it. Of course, I knew that. Of course, anyone who understands estrogen and PCOS is going to expect that to be the case, because if you can’t make energy in the heart, what’s it going to do? It’s not going to do very well. That’s another thing. 

Women with PCOS get tricked into getting pregnant in a way you got tricked. By the way, I was on Clomid. I got tricked. But no one prepared me. I don’t know if anyone did anything with you to try to help us be healthier before they tricked our body into ovulating. That what happens in women with PCOS and also when they do IVF. But women who do IVF because they’re not getting their infertility patients with PCOS, they have the highest failure rate of anyone. Why is that? Well, because their ovaries are very inflamed. You don’t have inflammation in one or two organs. It’s in every organ. Even in the ovary, they’ve done studies where they take follicular fluid out from around the egg and guess what they find? It’s permeated with inflammatory cells. They have ovarian inflammation. 

By the way, low progesterone is related to inflammation. Inflammation will drop the production of progesterone. And so, that’s a sign when you have low progesterone, you have luteal phase defect. You have inflammation. Work on the body. Don’t just trick the body into getting pregnant because we’re so clever. Because once you trick the body into getting pregnant, women with PCOS have the highest rates of pregnancy-related complications, miscarriages, everything that can go wrong. It goes wrong in higher amounts. Gestational diabetes, hypertension, preeclampsia. abruptions, both babies that are too large because they get too much sugar because of the gestational diabetes and babies that are growth restricted because of placental dysfunction, because of vascular problems. Because in the end, you can think of PCOS as a vascular problem, because the arteries are inflamed and that creates damage to the artery, and estrogen regulates the entire system that controls how the blood vessels constrict and relax called the renin-angiotensin-aldosterone system.

I just had an article published in December. You can Google it on PubMed. Go to PubMed or Google Scholar, and it was published, and it was a featured article. I was so happy about that in Mayo Clinic proceedings this past December of 21 and it talks about estrogen and the renin-angiotensin-aldosterone system, which is critical for immune function, which relates to vascular function, and they’re all intertwined because part of the inflammatory response is constriction of arteries to maintain blood pressure, so, you don’t go into shock, some sepsis, or blood loss. But the cardiologists and internists, they just think it’s just women get old and their blood pressure goes up or women with PCOS have hypertension, and they’re not thinking of the mechanism that it’s because estrogen is not properly functioning with this. This is a whole system of enzymes, the renin-angiotensin-aldosterone system, which we call the RAAS. 

It’s a whole system of enzymes that are located throughout every organ system in the body and in the blood. It’s so critical to regulating immune response for survival, so that you don’t go into shock and so on. But when you’re in a chronic proinflammatory state, you’re going to have proinflammatory constriction of blood vessels and that happens in pregnancy, and then they have vascular problems, and they end up with placental problems, and then you have poor nutrients, and blood flow to the placenta, and then to the baby. You have babies that are growth restricted, because they’re not getting proper oxygen and nutrients. So, you can have all these kinds of problems. Preterm deliveries. 

Oh, my goodness, we have to get women healthy before they get pregnant. And not just trick them in fertility centers into getting pregnant and then celebrate and walk away. And also, when you have an unhealthy female and this is so sad. Their babies are in an environment that’s unhealthy and they are more prone to having gene modifications that we call epigenetic modification and they are born already metabolically dysfunctional. They’re more prone to having things like hypertension, and obesity, and mental-emotional problems, ADHD. Even I hate to say this, but this has been published. Autism is higher in women who are unhealthy when they’re pregnant with PCOS. So, every woman out there who is interested in getting pregnant whether you have PCOS or not take time when to– We call it preconceptual counseling. You have to be optimally healthy before you conceive not just to lower your own risk to improve your fertility, to lower your risk of pregnancy related complications, but for the whole life of your child. 

Metformin isn’t the solution. I just have to do a call out here against metformin because metformin is used rampantly in women with PCOS. It’s actually officially an endocrine disruptor. It can alter hormone functioning in the body just what women with PCOS need. It’s also a nutrient depletor. It depletes the body of B12. But in terms of pregnancy, they did studies to look at it, because they wanted to give it to women who are pregnant to help them to prevent gestational diabetes. Well, it’s still given rampantly, but the study showed it didn’t do that. It didn’t do any of the things they hoped it would do like lower the incidence of preterm, well, slightly a few days preterm delivery in some women. That was the only benefit. But it didn’t lower preeclampsia, it didn’t lower hypertension, it didn’t lower gestational diabetes, it didn’t do any of those things. All it did was a few days, they had fewer women deliver at 37 weeks compared to 38. But it was a very small number, very, very small. Who knows what that really even meant? None of the things they were looking for happened. But when they looked and followed the babies who became little toddlers and little kids. 

By age four, the children who were in an environment in utero that the mom was getting metformin, by age four, those children were more metabolically unhealthy than matched women with PCOS. They match them according to all the criteria, who weren’t on metformin. In terms of their metabolic health they were, they had more visceral fat, they had more glucose, insensitivity to insulin problems, they had more insulin resistance. They were actually metabolically more unhealthy at age four than the kids who were not exposed to metformin in utero. That is not the solution, guys. Not the solution. In terms of understanding PCOS, you can see how it can really link to every woman out there. Lower your exposure to plastics, and chemicals, and pesticides, as much as humanly possible. Eat a healthy diet. And by the way, in terms of preconceptual counseling and this is actually spelled out a lot in my second PCOS book, that’s Fertility Fast Track book, I incorporate a lot of nutrition, lifestyle, and fasting to help women to really reduce inflammation, help their gut microbiome transform, help to restore gut integrity, and fasting, it has a lot of those wonderful benefits in the right population, of course. 

It always comes across as hopeless. I never want to end up sounding like, “Oh, my God, you are cursed women out there. You have PCOS.” Because the first step is to define the problem. We have to be honest. If we don’t define the problem, how are we ever going to solve it? That means being blatantly honest even when it hurts to really understand like, “Okay, you can look at Earth. Okay, Earth, you’re in a bit of trouble. Now, you know with pollution and weather problems.” So, you got to define the problem even when it hurts. That’s true for women with PCOS. We have to just spell it out. But then once you define the problem, then you can come up with really efficacious true solutions. Not just white washing, like, you have a wall full of termites. I don’t really want to deal with that. So, I’m going to just put wallpaper, nice, pretty wallpaper on that wall. But you know what, the termites are in that wall. 

When you’ve put birth control pills into a woman, she is actually more inflamed. She has lowered production of this really critical antioxidant, immune -regulating gas called nitric oxide and she has more gut dysbiosis. That’s actually been shown. There was one little study, because nobody cares enough to do more studies that showed more circadian rhythm dysfunction, like, your altered timing in your brain and your master clock that helps keep all your organs working in the same time zone. You really don’t want your pancreas working in Central Time, your stomach in Eastern Time and your liver in Pacific time. But that’s what’s happening in women’s bodies with PCOS. We don’t want that. We definitely want to look at all the different things that are really going on but then we have solutions. That is so important that if we define the problem, it looks grim. Okay. But there’s so much hope, there’s so much we can do. But none of it is a birth control pill, and none of it is metformin, and none of it is going to happen spontaneous combustion. So, that means everyone has to work really hard. This is a labor, really of love for yourself, for your future children, for everybody who loves you that you’re going to do the work to actually get healthy. 

And you know what, if you and I, I had to discover I had PCOS because nobody was helping me. I used fertility drugs from my first and then it’s like, “Okay, I get it.” Then I evolved and then I had more kids spontaneously. I had two kids that were over nine pounds. My biggest baby was 9.6. That’s a clue I had. I’m not big. How did I have a monster baby 9.6? Clearly, I had a glucose regulation problem. And then, now, my kids, it goes to the next generation. We tell them, “Okay, you have to eat healthy guys. You have a risk right here for yourself.” By the way, for PCOS, 50% plus will have a first-degree relative who also has PCOS. Even the moms of PCOS women who say they didn’t have PCOS, they have a 60% higher risk of developing diabetes in their life because there’s something still going on in them that is probable. So, they have a higher risk of diabetes even if they didn’t have PCOS, because they probably have some of the PCOS genes. So, nothing is so simple. There is a genetic propensity that we are activating and worsening all the worst genes or the best genes, but we’re turning them on their head. We’re turning something that was okay and minor and insignificant or even beneficial in ancient times into something pathological today. But we can turn it back around on its head and we can come out on top all you PCOS gals out there. Don’t think it’s hopeless.

Cynthia Thurlow: No, and I think for listeners to understand, this is one of many reasons that I wanted you to come on. Because you’re just such a breadth of experience and sharing the research, and sharing clinical applications. Every single question I had written down, you answered without me even prompting you. But one thing I want to reemphasize. It wasn’t until I struggled with infertility that I went to my mom and my aunts, and sure enough, they probably all had mild PCOS. They all had used Clomid.

Felice Gersh: Oh, gosh. [crosstalk] 

Cynthia Thurlow: I kept saying, “Well, why aren’t we talking about this?” And so, I think it’s important to make sure that you’re having those conversations with your moms and your grandmothers, and finding out if people have struggled with any of these issues. Now, I want to be respectful of your time and we are going to have a second episode talking about perimenopause and menopause, but I’d love to end talking about supplements and other ways that we can address PCOS. You’ve alluded to, we have a shared love for intermittent fasting. I know you talk about prolonged fasting. But to me, one of the things that was really interesting when I was doing research for our conversation is that for PCOS women, as you mentioned, they have the circadian dysregulation. They are already at a disadvantage that they are not going to have high-quality sleep. One of the first things that you talk about in your book is light exposure, sleep quality. What are some of the other things along with some supplements? Because there are some special ones in here and I’m glad that you-

Felice Gersh: Oh, yes.  

Cynthia Thurlow: -addressed metformin, because I get that question a lot. But things like myo-inositol, they are so helpful for PCOS women. 

Felice Gersh: Oh, absolutely. In terms of lifestyle, it’s really all the fundamental lifestyle issues, but really taken to their ultimate level. Because women with PCOS have the ultimate metabolic challenges here. In terms of sleep, absolutely, you need to do sleep hygiene, which means getting away from all those blue light screens and really as longer is better. So, preferably a couple of hours would be really good. Watching the sunset, the colors of the sunset actually help to lower cortisol in which women with PCOS tend to have high cortisol at night and low in the morning, a flip, because they have a flip circadian rhythm. The reason for that is that estrogen works the master clock that helps to set all the timing for the different organ system. Women with PCOS do live as if they’re in a jetlag situation, which is associated with actually all the metabolic and symptomatic things of women with PCOS. All of you women out there who work night shifts, you actually have a lot of the same challenges. So, keep that in mind and see if you’re nurses, or police officers, or whatever, you can get seniority fast and do whatever to try to get on the day shift. But women with PCOS do have this. We want to help them to sleep because they do have a lot of sleep problems. Sleep is not the absence of awake. Sleep is when you have gigantic blood flow to your brain, it cleans house. You have changes in hormones that are very dramatic. All kinds of changes in your cardiovascular system, your blood pressure should drop, you actually make growth hormone, which helps to build lean body mass, which you don’t have enough of when you have PCOS, muscle, which is the most important fat burning organ structure and glucose burning structure in your body is muscle mass. So, sleep is definitely essential to health in a myriad of ways. Women with PCOS have a lot of also altered sleep, breathing problems, sleep apnea. I get a sleep study on all of my patients, because estrogen works in the brain. There are receptors all over including the centers that deal with breathing at night. And of course, some women are also obese. They tend to have obstructive sleep apnea from their tongue and so on. 

But even so they’ve central sleep apnea, which has to do with the breathing mechanisms that are triggered to the autonomic nervous system, even part of the nervous system that controls things we don’t think about like breathing, and heart rate, and blood vessel status, and so on. Sleep is critical. You want to go to bed preferably by around 10 o’clock, you want to get that surge of melatonin at 2 AM. You want to avoid all the blue lights for a couple hours. There’s so much you can do besides watching screens. You can listen to wonderful podcasts. Just don’t do the video. You can do books on tape, you can play board games, you can actually write, you can clean your house, you can do the laundry, [laughs] you can talk to your partner, I mean, you can do a bunch of stuff. So, you can actually listen to television, if you just put a giant towel over the screen, because I have listened to many television shows while I’m cooking and I don’t see a darn thing and you can follow what’s going on. So, you just turn your TV into a radio, it’s fine. So, there’s plenty you can come up with, guys, that besides like watching computer screens, and television, and so on. Your iPhone needs to go into turn it upside down mode, so, you’re not looking at it. So, that’s so critical to get adequate sleep. 

In terms of supplements, a little bit of melatonin is the way to go. For most people, it’s best to start with small amounts, like, a half a milligram a couple of hours before to welcome sleep rather than using melatonin as a drug. Now, sometimes, I do that short term. In young women, they should have the capability of making melatonin which changes when you’re 80. Basically, try to use small doses. Half a milligram will often be a place to start a couple of hours before you go to bed. And sometimes, some of these herbals like ashwagandha, lemon balm, L-theanine, which comes from green tea, passion flower, these can be very nice and their blends and you can do it in teas, you can do it in capsules, and so on. Some of the calmatives can be very helpful. And of course, mind-body medicine which is essential. I love guided imagery, you can learn meditation, there’s progressive relaxation, there’s tapping. So, there’s a variety of forms of mind-body medicine.

I love body work, like, who doesn’t love it relaxation massage? But maybe a spouse you can get lovely essential oils that can also be very calming and so forth. That’s great for sleep. In terms of light, that is so important. At night, I sleep with a sleep mask or else you get blackout blinds. You got to be in a very dark, cool room. I have a fan blowing on me. That’s wonderful. It’s like, “Ooh, sometimes, it’s chilly. I’ll pull up the blanket.” That’s good than being sweating and hot. That’s really not going to be great for sleep. In the morning, bright light will help to set your master clock to keep it from the word that we use is drifting, literally drifting. You can get bright light by opening all the windows and the blinds. You can get a light simulator kind of a thing like a light box and put it at 10,000 Lux for 30 minutes every morning, try to get midday Sun, and try to get outside without sunglasses for at least 15, 20 minutes. And if wear contacts that are tinted try to get out without them because you’re trying to get like to go into the receptors that are actually in the retina of your eye that go directly to your master clock to help set it. Light therapy is really important.

And then nutrition, of course, you need to have all the magical polyphenols. I call them the special sauce, a plant-based diet. I recommend going vegan for a few months, because when you’ve the wrong gut microbes, they actually metabolize animal protein to create toxins like TMAO. And so, it’s best to have either minimal, no more than three ounces or just go on a vegan diet for a few months. Not forever, but really, you want to nurture your gut microbiome. They love plants, they love fiber, all kinds of fiber, and you want to make sure that you eat across the colors of the rainbow for all the different types of nutrients. And the polyphenols is actually a dance with the magical polyphenols. What’s interesting is that many polyphenols and people don’t recognize them, they’re actually phytoestrogens that they don’t even get it. People know isoflavone that come from legume. Not just soy, but all the beans and lentils all have isoflavones in them. Not just soy. If you don’t like soy for whatever reason, organic soy, unless you have an allergy to it is actually a fertility food. Because it’s an isoflavone. It actually binds to estrogen receptors, the beta. That’s the type that’s predominantly in the gut to help restore gut health. 

But other things, the skin of red grapes have resveratrol, which resveratrol is a polyphenol and it’s a phytoestrogen. From pomegranate, it can turn down the road into Urolithin A which is also a phytoestrogen. Nuts and seeds have phytoestrogens. Seeds often like people talk about flaxseeds, they have lignans. Lignans are phytoestrogen. A lot of the magic that comes from polyphenols are actually because they’re phytoestrogens and they’re like magic. They bind to estrogen receptors, but they’re not estrogen and they have all kinds of amazing beneficial effects. They can even go into the circulation, and bind to estrogen receptors elsewhere, and create all of these benefits that are amazing. So, many, many fruits, vegetables, legumes, beans, nuts, seeds, all have this magical property of being phytoestrogens, along with having wonderful fiber, and all the antioxidants, and minerals, and so on. Because you need all the right nutrients, macro and micro to run the machinery of your cells.

If you don’t have enough B12, you’re a goner. [chuckles] I’m just telling you. You got to have it all. That’s why I do recommend a good prenatal vitamin. Because you can’t take 200 supplements. That’s like a little over the top. But a really high-quality prenatal vitamin will at least have all the basics. Get it with methylated Bs, in case you have an MTHFR, which is another topic. In case you have a genetic issue that you don’t do this magical process called methylation, well, you can have premethylated folate, premethylated B12 that for most people is going to serve you well. So, that would be great. 

Then fitness, exercise, the ultimate best is interval training, high intensity interval. But you can’t start with that. We don’t want injuries, because you’re more likely to have weaker joints and inflammation in your joints. I really recommend working with a personal trainer who knows what they’re doing. Because you got to look at what was their training. Look for someone who’s certified by the American College of Sports Medicine, not by a gym, okay? American College of Sports Medicine. That’s the epitome of organizations that trains personal trainers and they know what they’re doing, because I don’t want anyone to have an injury. But work your way up gradually. But any movement is better than no movement. And so, sedentary lifestyle is the worst. They came up a few years ago with sitting is the new smoking. It’s so toxic to the body to just be sitting, sitting. By the way, they’ve shown that fidgeters, I would like to tap my feet, la, la, la, la, la. Fidgeters actually burn a substantial number of calories that help to keep them healthier and thinner. Don’t sit still. March in place, tap your feet. If people find you annoying, okay, then stop. But do it when you’re in private. 

Don’t just keep moving and find something you love the people that will do it with you, because it’s really hard to stick with something you hate. I say, find recipes with all the vegetables that you love. There’s so many out there. My mom, she tried, but she made everything taste like a soggy mess. I never got to feel good about vegetables. But now, I love them because I learned how they can actually be cooked and that you don’t get a box of frozen mushy spinach. That was the day. [laughs] But now, you can get wonderful fresh stuff. If you don’t have a farmers’ market, then go and buy the best organic food you can. That’s where you spend your money as much as you can and be skimpy on something else. But don’t try to save money by buying crappy food. And so, you want to also time your eating. That’s the backdoor way into getting your circadian rhythm reset is to timed eating, what we call creating synchronization of your organ systems.

I usually recommend based on studies that actually were done for women with PCOS that you try to put most of your food into the early part of the day and very little at the end of the day, and not eat more than three times a day. That means column three meals. I don’t care about labels for meals, because you can eat any food at any time. There’s no special breakfast, lunch, or dinner foods. They’re just meals. It’s best to actually have breakfast be your biggest meal, and then have two-thirds of your calories for breakfast, one third for very early dinner or late lunch. But most people won’t do that. You have to be realistic. Then try to either have your biggest meal breakfast or else, make it lunch and try to have an early small dinner and then stop eating. You have to have at least 13 hours from dinner to the next breakfast. Please don’t skip breakfast because that’s when your body is most genetically aligned to digesting food, keeping your insulin down. You can eat the same foods at night or in the morning and you’ll have a totally different insulin and glucose response. It’ll be much better if you eat it in the morning. 

That’s why we say in the book, “If you have to have dessert, eat it with breakfast.” Because your glucose will raise to a higher level at night, but much lower if you eat that same dessert in the morning and your insulin will be more actually functional. Insulin receptors work better in the early part of the day and they work less well. Everything is on a timer. Digestion is better. You’re more likely to get heartburn, indigestion if you eat at night. Most people figure that out. But then the solution isn’t to take pharmaceuticals, like, they advertise on TV, acid reducers and things. Their secret is eat according to your body’s genetic programming, which is in the early part of the day. And then I’d mentioned about stress and toxin exposure. You want to try to avoid plastics, bring your own cups when you go to a place like a Starbucks or something and have them fill it, like stainless steel or tempered glass, try not to use. When you put on those covers, those lids, they’re terrible. They’re all, what we call, phthalates. They’re soft plastics and they all get absorbed into the heat, the hot liquids, and they’re poison.

For men, they’ve had tons of articles showing that they destroy their sperm. [chuckles] Their sperm counts are plummeting. Men out there and you have men in your lives in some form or fashion, tell them don’t do that either. All this actually does apply to men because we’re all human beings on planet Earth. Well, Earth plays with the same kind of circadian rhythm issues. We can do all of these things. In supplements, in a nutshell, myo-inositol is my ultimate favorite. It works in the ovary in women with PCOS to improve their egg quality, improve estrogen production, and improve ovulation. What a fantastic thing that is? There is multiple, like around seven inositols. They’re actually sugar alcohols and they’re all the same molecular formula, but they’re arranged differently in space. So, we call them stereoisomers. Here’s my hand, this is still my hand. It’s just in different arrangements. So, those are stereoisomers of my hand. 

There’s a lot of talk in the PCOS world about D-chiro versus myo. In a normal healthy reproductive age woman, the ratio of myo-inositol to D-chiro is 100 to one. A hundred times more myo than D-chiro. In women with PCOS, it tends to be about 12 to one. So, only 12 times as much myo as D-chiro. Not nearly enough myo. The liver uses D-chiro predominantly for glucose regulation and glucose production. But the problem is that D-chiro in the ovary actually blocks ovulation and it blocks the action because it acts as a blocker. It blocks myo-inositol. I don’t use D-chiro at all. When they sell it in the ratio like 40 to 1, that’s based on data that that they think is the normal ratio in the blood. Well, that’s not the ovary. And also, who says that if you swallow it, even if it really isn’t a 40 to 1 that it’s going to get into anything in that ratio. And in the gut, there’s actually data that in the gut, when you swallow it, D-chiro blocks the absorption of the myo. Just do all the lifestyle stuff. Don’t take D-chiro. Just take the quality myo-inositol, two grams twice a day. 

You can also use berberine as a replacement for the metformin. Because it also is an insulin sensitizer, it works to kill off bad gut microbiome, and it is very good for the cardiovascular system. I don’t usually like to use it indefinitely, because I’m never sure if I could be doing anything to good microbes. You never kind of like antibiotics. But we just don’t have the data. But it’s an alkaloid extract from a number of different plants like Oregon grape root and there’s a lot of published data that is very positive on berberine. In fact, there was some studies comparing the effect of metformin and berberine on IBS and berberine won. Whenever they compare lifestyle and metformin, guess what, lifestyle always wins, too. Berberine is another one of a very good choice. NAC, N-acetyl cysteine, which acts as an antioxidant, and it helps with glucose transport, and it has been shown to help improve ovulation as well in women with PCOS. It’s also great for menopausal women. They’re not all single use, nothing has just one effect. 

And then most women with PCOS are vitamin D deficient. But you can’t just pour endless amounts of vitamin D into women. Because what happens is vitamin D is fat soluble. It can get stored in fat tissue and so, the amount in the blood is going to be low when you measure it, but the total body content of vitamin D can actually be getting higher and higher. You don’t go above 5,000 use a day, please. No matter what the level is. You can’t just keep pushing it. It’s getting in. It’s just getting in the fat tissue. What we need to do is all the lifestyle stuff, so that we can actually have some weight loss and deal with that problem. So, don’t just keep pouring endless amounts of vitamin D. Remember, it is actually stored in the body long term. Don’t just think it’s bottomless pit. Don’t do that. 

In terms of others that can be very helpful. CoQ10 can be very helpful to help with the mitochondrial function. Curcumin can be very helpful, because it’s amazing as an anti-inflammatory. There’s just endless– Quercetin is amazing as a polyphenol that helps to stabilize immune cells like mast cells, so that you reduce inflammation. I always tried to be aware of what I call a problem of a lot of functional naturopathic and integrative doctors. They create a problem called, I named it colitis for too many pills. I try to temper my enthusiasm of prescribing too many supplements and going with what’s actually manageable for people and focusing on the most key issues for them. But those are ones that are very, very key along with, like I said, good prenatal vitamins, so, you don’t have to take a separate everything. 

Women who have cystic acne, then I would definitely include more vitamin A. You have to look at the individual and what’s going on with her. I check levels. I monitor, and then measure, and then monitor again. So, definitely, it should be individualized. That’s what I talk about personalizing it. Because everyone is unique. It’s a spectrum. It’s a syndrome, and so you want to focus. And then if they have a lot of gut problems, you’ve got to focus on gut health. I give [unintelligible [01:14:28] and I definitely give L-glutamine, sometimes I give now butyrate. We’ve got to help restore the gut through both diet and some targeted supplements. I usually start my patients with what I call a reset for a month. It’s to help reset their diet if they’re eating garbage unfortunately like the Standard American Diet, I try to give them the proper foods and then a few supplements to try to restore the integrity of the gut lining cells, they’re all so important. So, we don’t want have perpetual gut problems with lots of leaky gut and so on.

These are complex things. But there’s so much you can do on your own. That’s why the books that I write are self-help. I use pharmaceuticals sometimes. I need to be honest, I’m an MD. I prescribe hormones. I have to give progesterone to induce periods. I can’t let people risk getting uterine cancer. If their estrogens are really low, I will give them bioidentical estrogen, just like I would give to menopausal women because you can’t heal without estrogen. If you’re going to get them to make more, you sometimes have to start them off once again, like, training wheels. In some cases, when women are hundred more pounds overweight, I will give them pharmaceuticals like the GLP-1 agonists like semaglutide that’s out there. 

But as tools and bridges to help with an end game, like, an exit strategy, which is not usually present among the endocrinologist, they started drug with no idea of what’s going to happen in one year, two years, five years, 10 years. What’s your strategy long term? They have no strategy long term. We always have a long-term strategy. So, I look at the pharmaceuticals. I use as a bridge and as support to getting health back restored. I don’t talk a lot about pharmaceuticals and such in my books because you can’t access them yourself. So, these are all the self-help approaches, which are massive. And for many women, you don’t need to go on pharmaceuticals when you do these lifestyle changes.

Cynthia Thurlow: Well, Dr. Gersh, I’m in awe of the incredible knowledge and breadth of your expertise. I really look forward to bringing back to talk about perimenopause and menopause, because there’s so much to unpack. But I know this is an invaluable podcast and the information that you shared. I mentioned earlier, I had all these questions written down and you beautifully wove into your conversation all the questions I had. For listeners that are listening to this podcast and want to learn more or want to connect with you, please let them know how to find you on social media. You are active on social media. How to get access to your books? We’ll put all the links in the replay. But please, let them know how to connect with you.

Felice Gersh: Well, I am an old-fashioned doctor. Actually, I’m talking to you from one of my exam rooms like, oh, here’s an exam table, right?

[laughter] 

Felice Gersh: I don’t have a studio. I actually have patients after this. I see patients’ telemedicine and also hands on. And so, of course, if people want to, they can come see me in person or telemedicine. I’m on in Irvine, California, lovely Southern California. My practice is called Integrative Medical Group of Irvine. I do have an Instagram, which I tried to do a few times a month and get some information out there. And so, you’ll have the link, I’m sure. All of my books are readily available on Amazon and some other sites. But Amazon is the easiest one to go with. I hope to be around for a long time, because it’s so fun and there’s nothing that giving is the best way of receiving, right? So, I’m happy to join you now anytime in the future, because you have a big voice and a big platform here. I don’t have a podcast. I just don’t have the bandwidth for all of that. And so, I really appreciate so much people just like you who are really helping me and many others to educate the population, because everyone is not going to end up in my office. I realized that. And it helps you to make choices and to control your own life. But I’m here, for anyone who wants to access me, or my books, or my little Instagram Live.

Cynthia Thurlow: Thank you, Dr. Gersh. It’s been a pleasure. 

Felice Gersh: Mine, too. 

Cynthia Thurlow: If you love this podcast episode, please leave a rating and review, subscribe, and tell a friend.