Recently, I interviewed Dr. Felice Gersh, and we talked about PCOS and its connection to thyroid autoimmunity. If you would prefer to listen to the interview you can access it by Clicking Here [1].
Dr. Eric Osansky:
I am very excited to chat with Dr. Felice Gersh, as we are going to be talking about polycystic ovarian syndrome (PCOS), diving into hormones, especially estrogen.
Let me go ahead and give Dr. Gersh’s impressive bio: Dr. Felice Gersh is a board-certified OB-GYN in integrative medicine and is a multi-award-winning author, speaker, and busy clinician. She was one of the first board-certified integrative gynecologists in the United States. She is the author of multiple bestselling books, including PCOS SOS: A Gynecologist’s Lifeline to Naturally Restoring Hormones and Happiness; PCOS SOS Fertility: The 12-Week Plan to Optimize Your Chances of a Successful Pregnancy and a Healthy Baby; and Menopause: 50 Things You Need to Know: What to Expect During the Three Stages of Menopause. She combines the most evidence-based, safest, and efficacious ways of helping all women of all ages optimize their health. Thank you so much, Dr. Gersh. It’s a pleasure having you on the podcast.
Dr. Felice Gersh:
Thank you for inviting me. I’m really excited, forever and always, to get to talk about my favorite issue that so many women face: PCOS.
Dr. Eric:
With that being said, let’s give a little bit more of your background. How did you focus on PCOS? Obviously, you’re an OB-GYN, and you deal with women’s health issues and hormones. You have a great deal of experience with PCOS, so if you could talk about that please?
Dr. Felice:
This is a familiar story in many ways for us in healthcare. We do often get the most interest in our own personal journeys involving our own health. I had to diagnose and treat my own PCOS, and I didn’t get any help from highly respected OB-GYNs in my medical school, my residency. Finally, I had to do my own deep dive and discover that the reason I went two years without a period, I had endless acne issues, and I couldn’t get pregnant was because I had PCOS.
I saw in my own private practice so many women developing PCOS, many more so than I saw in the early stages of my career when I was a resident. This is an epidemic now. So many of them came to me after seeing many previous doctors and didn’t even get a diagnosis, let alone a therapeutic approach to treating it.
Like so many of us, we just took the bull by the horns, and I had to figure it all out. Looking at the science, the data, and doing a deep dive into what is going on in the bodies of women with PCOS? Whenever you hear the word “S” for “syndrome,” it means it’s a grab bag. It’s an all-inclusive syndrome. That means there can be different etiologies. You have to go through and see what is the underlying cause?
That’s where the integrative approach becomes so critical. We don’t just treat symptoms, which is not an insignificant thing to do. You do want to treat symptoms. But we want to get to the basic root causes as much as possible to try to really resolve the problem, not just cover up symptoms. It’s been an ongoing journey for me for decades, trying to unravel this issue.
After many years of starting and never finishing, I got together with my brilliant daughter, who is my co-writer on all my books. She put me on a schedule of delivering this chapter and dictating for her. Together, we got our books written on PCOS and continued the journey of treating PCOS, educating on PCOS, and helping women all over the world to deal with this very common but often devastating healthcare condition.
Dr. Eric:
You mentioned very common. How common is it?
Dr. Felice:
No one keeps good data. From the best we can judge, it’s anywhere from 10-20% or more of reproductive-aged women. It doesn’t go away when you hit menopause; it blends into the other issues that women with menopause are dealing with. Now finally, it’s been recognized—it wasn’t for many years—that women who have had PCOS for all their reproductive years, when they get into menopause, they have a higher rate of developing cardiovascular disease and other issues involving metabolic dysregulation. It’s not like it disappears. It just becomes less readily evident because of some of the symptom changes. The underlying metabolic changes and underlying risks remain and are actually accelerated in women who’ve had PCOS.
It’s such a prevalent thing. When you think about it, the bare minimum is 10% of reproductive-aged women. I really think it’s closer to 15 or even 20%.
When I was talking about PCOS a few years back, a little before the pandemic, I was in India. Nobody wants to admit they have PCOS there if they are women in India because it’s a fertility problem, as well as other things, and they don’t want to have that stigma. They think in that particular population, it’s well over 30% of young Indian women who are dealing with PCOS. It’s a worldwide problem. There is no continent that doesn’t have it. In fact, some of the best research on PCOS has come out of China and Iran. It’s amazing how this problem is everywhere in every group, every ethnicity.
Dr. Eric:
Wow, 30%. Even 10% is pretty high, so 30% is really astronomically high. Like most other health conditions, do you find that it has been increasing over the years compared to 10-15-20 years ago?
Dr. Felice:
Absolutely. That has been not only my observation, but it’s everyone’s who is in this field. We believe it’s driven by modern lifestyle changes. What we call the SAD diet (Standard American Diet), filled with processed foods, devoid of essential nutrients and fiber.
The loss of our vital Circadian rhythm due to all the blue light exposures and lack of adequate sunlight. People are often in rooms with no windows, or they’re covered. They have all that blue light, television, computer screens, phones, that they look at into the wee hours of the night often. Sometimes, people are checking their cell phones at 2am and getting that blue light into their eyes.
The loss of activity. The sedentary lifestyles that so many people are leading.
The ubiquitous chemicals, the endocrine disruptors. These chemicals that interfere with the normal hormonal signaling functions in the body, particularly estrogen. Endocrine disruptors that we call xenoestrogens.
It’s the conglomeration of all of the things that have changed in the world since ancient times. Now, people live longer, and that’s fantastic. But we have a whole new array of medical issues that we’re confronted with. This great increase in the incidence of PCOS is one of the offshoots of modern living. The chemicals, the diet, the stress, the change in sleep habits, light exposures, and so on have all joined together to exacerbate the underlying issues that are causational in terms of PCOS.
Dr. Eric:
The endocrine disruptors are still very rampant. Especially with bottled water, you’d figure that fewer people would drink it. I think there is more awareness. It’s in the research; it’s not just people saying that bisphenol A (BPA) and these other endocrine disruptors are issues. If you walk into Costco, it’s amazing how many cases of bottled water there are, and people drink that every day. I assume a lot of people listening to this are not doing that, but in general. I’m not surprised you mentioned that.
Getting into the Circadian rhythm and blue light, you’re saying that not getting enough sleep and being exposed to blue light could also be a developmental factor?
Dr. Felice:
Absolutely. It’s all related. I’m glad you mentioned BPA. BPA is the endocrine disruptor that has the most research in women with PCOS. I’m sure they’re all involved, and there is some about phthalates, the pervasive scents and soft plastics. BPA, they have shown that in women who are pregnant, the BPA in them- BPA is in so many different things, like plastics and can liners. It used to be in dental sealants, baby bottles. It’s in almost every single person when they test for it. It actually concentrates in the fetus. The levels in the mother are significantly lower than the levels in the fetus.
This is a very powerful endocrine disruptor. When the endocrine system, the hormonal system of the body is being developed during fetal times, it only gets one chance to be developed properly. What they’ve found is that the receptors for estrogen, and there are three types, but the alpha and beta are altered in women who develop the worst PCOS because of these exposures in utero. Like I said, the most research is with BPA.
It turns out that estrogen that comes from the ovaries, estradiol, known as E2, because there are three estrogens in an adult female. E1 is estrone. E2, which is the one the ovaries make, estradiol. E3, which is estriol, the dominant estrogen that the placenta makes in pregnancy. It turns out that inherently, genetically, women with PCOS have a little bit less ability to convert testosterone, the precursor hormone that is also made in the ovary, into estradiol through the action of an enzyme called aromatase.
Now, that is a very mild deficiency of estradiol in a healthy woman from ancient times. But now, this problem of not adequately producing estradiol becomes magnified in ways we’re still learning about in women with PCOS. It’s like fuel to the fire when you don’t make enough estradiol in the ovary, and then the estrogen receptors are not working well. They are not receiving so well. The signaling function of the hormone is sub-optimal because the receptors are not as receptive because of the impact in uterine life. Also, probably at key times during puberty.
In fact, when they have done levels of adult women with PCOS, they’re finding higher levels in them even as adults. Not because they are exposed to more, but maybe genetically, they are not as good as getting rid of it and processing it through the liver. It’s this whole perfect storm in women.
It turns out that estradiol is really critical for managing and maintaining our master clock, which sits atop the optic nerve in the hypothalamus portion of the brain that helps to control all the timing of our organs and our Circadian rhythm. When you don’t have enough estrogen being made by the ovaries, or the receptors aren’t working properly, you innately have a state of jet lag. You’re living across different time zones. That is a disaster for metabolism, which is creation, distribution, and utilization of energy.
You have this problem. When you compound it, that is why it’s always an insult to injury by getting too much blue light, not getting adequate sunlight, going to bed at the wrong time. Then you are taking, once again, a problem that is already there and making it that much worse.
I always say the first step in solving a problem is to understand it. That is why it’s important to understand how foundational it is to have the Circadian rhythm, to have light, to have the right foods, to have a healthy gut. All that plays into having a healthy metabolism and a healthy reproductive system, how it’s all intertwined. All of this is in disarray in women with PCOS today.
Dr. Eric:
I want to talk more about estrogen. When it comes to testosterone, you mentioned the problem with conversion of testosterone into estradiol. Is that why one of the characteristics is higher androgens, higher testosterone?
Dr. Felice:
That’s totally perceptive of you. That is correct. Remember, PCOS is a syndrome. I’m going to talk about what we’ll call classic, or the most conventional form of PCOS. It’s also other ways that you can have the manifestations that are very similar, but they’re actually from different underlying causes. That’s what makes it confusing to a lot of people.
Let’s call it the mainstay type of PCOS. If you think of it as an assembly line, first, the ovaries make testosterone. Then the testosterone moves from one part to a different part of the ovary. It moves to the granulosa cells, where the enzyme aromatase, under the influence of the hormone from the pituitary gland called FSH (follicle stimulating hormone) converts the testosterone into estradiol.
Now, the pituitary gland, under the influence of the brain, makes LH (luteinizing hormone). That is the hormone that tells the ovary to make testosterone. The brain has censors. It’s mastering everything, keeping control, keeping tags on everything. If the brain notices there is not enough estrogen being produced from the ovary, it will put out a signal to the pituitary to make more LH because from LH, you will then trigger the production of testosterone. All estradiol that is produced in the ovary, E2, is derived from the conversion of testosterone.
The brain says, “Please, ovaries, make more estrogen.” It tells the pituitary gland to tell the ovary to make more testosterone. But, uh oh. There is a snag here in the assembly line. You’re making plenty of testosterone. Totally different skillset to make testosterone. You are not efficiently converting it into estrogen. You end up with too much testosterone, not enough estrogen. The brain keeps saying, “Where is my estrogen? Make more.” So it keeps putting out more LH through the pituitary, and making more testosterone.
Now, when you have more testosterone, it actually begets more testosterone. It changes the gut microbiome. When you have an altered gut microbiome under the influence of testosterone, it turns out that it stimulates more testosterone. Then you have all that testosterone, not enough estrogen. It creates inflammation in the body through an altered gut microbiome. There is a whole bunch of different mechanisms that come into play. When you have more inflammation, you have more insulin resistance. Then you have more insulin, which also triggers through the increased production of another little hormone called IGF1 (insulin growth factor 1), which can move into the ovary and trigger the ovary to make even more testosterone. You have inflammation, insulin resistance, more testosterone adding fuel to the fire.
You can see where this dynamic is going. You have a woman with not enough estrogen, too much testosterone, too much inflammation, insulin resistance, abnormal gut microbiome, leaky gut. It’s like metabolic havoc.
You have to look at each part of the equation to help each woman to overcome what’s going on in her body that is causing so much havoc. Because of the elevated testosterone, women with PCOS often will get cystic acne in the jawline, which is very resistant to conventional treatments. It’s very difficult to clear it up.
They will often have facial hair, and they have to deal with electrolysis, laser, shaving. There is extra hair that is not making women feel feminine. They have the female version of male pattern hair loss, which is called androgenic alopecia. They often have fine, thin hair, which also isn’t feeding their egos either.
Because of all of these problems, they are not ovulating because the same trigger to making the estrogen is also helping to trigger ovulation. That is not happening regularly. They are having irregular cycles. They are having infertility. PCOS is the #1 cause of female infertility. They have very high rates when they do get pregnant of complications because of all this inflammation and insulin resistance going on in their bodies. They have high rates of miscarriages, preeclampsia, gestational diabetes, hypertension, babies that are too large or too small because of placental problems, preterm delivery. It’s a really huge problem in terms of their overall body health and their reproductive function.
Dr. Eric:
If I’m understanding you correctly, it seems like all of this is stemming from too much testosterone caused by the lack of conversion of testosterone into estradiol. The excess testosterone alters the gut microbiome, causes inflammation, which leads to insulin resistance, which I was going to talk to you about. It’s a whole vicious cycle. It sounds like testosterone, that conversion process, is the culprit.
Dr. Felice:
Well, that’s the initial. When you add in, like I mentioned, that the estrogen receptors in the body are malfunctioning because of exposures to endocrine disruptors, it’s adding that much more level of complexity.
It turns out that estrogen in the form of estradiol, which is the form that is essential from the ovaries, that hormone has receptors in every single organ system of the body. It’s key to regulating our gut function, neurological systems, cardiovascular systems, musculoskeletal systems, skin, and so on. It turns out if you have malfunctioning of the estrogen receptors, they’re not as sensitive.
A lot of people have heard of insulin resistance. The insulin doesn’t work properly because of resistance of the receptor. That is the same thing. You can think of it as estrogen receptor resistance. It’s caused by the exposure to these endocrine disruptors.
Without adequate estrogen being produced in the ovary, and without adequate function of the receptors, then it’s just that much worse because estradiol actually maintains the production of nitric oxide, which keeps arteries dilated and healthy, so you don’t get hypertension. It works to keep the proper neurotransmitters, like serotonin, dopamine, acetylcholine, which are involved with memory, focus, emotions of all kinds in the brain. It maintains the autonomic nervous system, so you don’t have sweating or problems with sleep and emotions and tachycardia. So many things are going on when you don’t have enough estradiol being produced, and it’s not functioning properly on the receptors.
Then you have all of this surplus testosterone, which is another big problem from so many perspectives. Having all of that extra testosterone is interfering as well in metabolic functioning, gut functioning, and of course, all the side effects that it creates, which are horrible for a woman’s life.
You can see, it’s a big deal. That’s why I’m so passionate about it. The only conventional treatments have hardly changed at all in many years. We need to think out of the box a lot more about how to approach this condition.
Dr. Eric:
Estrogen gets a bad rap sometimes. When you hear the term “estrogen dominance-” I am guilty of using that as well. In most cases, it’s the xenoestrogens and synthetic estrogens like birth control and oral contraceptives. That’s another question. Can taking the pill be a factor in the development of PCOS?
Dr. Felice:
I actually think so. I can’t prove it. This is a theory that I have been basically thinking about. It turns out that birth control pills, which are one of the mainstay treatments of PCOS- It’s clearly helpful in certain symptom control issues. It basically shuts down your ovaries. That whole thing I described about the assembly line, where you make too much testosterone, and it’s not converted to estrogen properly, that is shut down. If you take the ovaries offline, then a lot of that is going to be better.
When you have a lot of birth control pill estrogen on board, it increases a protein made by the liver called sex hormone binding globulin (SHBG), which helps to bind up excess testosterone that is circulating. That can help with acne.
When you are on birth control pills, it’s not real human hormones. Actually, if you looked at it on Toxicology.gov, which is a division of the National Institutes of Health (NIH), the ingredients in birth control pills are technically endocrine disruptors themselves designed to prevent fertility. It’s used in other ways, these hormonal but fake human hormones. They are not human hormones at all. They can disrupt the way the ovaries work completely. They shut them down. Then you get the hormones that give you the illusion of having regular cycles. You have regular bleeding, but you are not ovulating. Your ovaries aren’t doing a darn thing. But it can improve symptoms.
Here’s the problem: they are not real human hormones. Most birth control pills have a chemical in them called ethanol estradiol. It’s not real estradiol. Just putting on that extra molecule changes everything. It’s a different chemical. It turns into estrone primarily when it gets metabolized in the body and through the liver.
Most of the estrogen that is circulating turns out to be estrone, which only binds primarily to one of the estrogen receptors called alpha. That creates an imbalance in the body. The ovaries make estradiol, E2, which has a balanced effect on the different receptors.
Remember, what birth control pills are are endocrine disruptors. That is what they are. You have a different effect. What is happening is that particular type of estrogen is more pro-inflammatory. That’s why women on birth control have higher risk of getting blood clots. Fortunately, because they are given to people who are younger, their incidence is so low. Even if you increase the risk quite a bit, it’s still in terms of absolute numbers going to be a low incidence.
The problem is that birth control pills can also tend to cause high blood pressure. That’s why we never give birth control pills to old women, to women who are smokers, especially over 30-35. We don’t give it to women who just had a heart attack. We don’t give it to women who have had blood clots of any kind, in their veins or lungs. We don’t do that. These are real risk.
Here is the problem: Women who have PCOS already have an inherent higher risk of blood clots and hypertension, high blood pressure. This is a higher risk group. There is published data to show that women who have PCOS and are given birth control pills have a higher risk compared to the average population of women of developing a blood clot. I feel that women with PCOS should be viewed similarly to women who have had prior blood clots or women who have uncontrolled high blood pressure or smoking women, older women, and so on. It’s a higher risk group.
Here is the other thing. When you are on birth control pills, you’re not activating anywhere near as much as you would normally the beta receptor. Mostly, what you’re putting into the body is estrone, which activates and binds to the alpha receptor. If you are on birth control pills for a very long period of time, the beta receptor may start to malfunction. We know this when we have done research in women in menopause. It’s a little bit of a use it or lose it. If nothing is working on the receptor, over time, the hormone receptor becomes less functional. It may or may not come back into pristine shape, or whatever best shape it would be in, after you give them the hormone that they haven’t had for quite a bit of time.
What I’m finding is women who have never had any sign in the past of PCOS got put on birth control pills because they had cramps, or they were sexually active at a young age. A whole variety of reasons. They didn’t have PCOS-like symptoms at the time they went on birth control pills. Then they are on them for 15, maybe even 20 years. Now, they’re in their early 30s and want to think about having a baby. Then they go off, and suddenly, they have every symptom of PCOS. They have irregular cycles, terrible acne, and growing hair. They go to their doctor and say, “You have PCOS.” I never had PCOS before I went on the pill.”
I think what’s happening is that it’s creating that problem with the receptors that I talked about, that women with PCOS have from their exposures to endocrine disruptors. Maybe it’s also impacting how the ovary itself is working because remember, when you are on birth control pills, the ovaries aren’t doing anything. They are put out of commission. The ovaries may be rusty and are working to create estrogen. There is something going on here. I have no published data. But my observation, and I do believe in observation. It’s a lower level of evidence than a peer reviewed, placebo controlled, double blinded study. Observation is how most every great discovery in the history of mankind was made, not through a pharmaceutical study.
My observation—and I think it’s valid, but I can’t prove it—is that long-term use of birth control pills actually can promote the development of PCOS in women when they go off of them.
Dr. Eric:
As far as alternative treatments, is it as simple as trying to minimize, if not completely eliminate, exposure to synthetic estrogens, birth control, xenoestrogens, doing things to detoxify estrogens from your body? Does it go beyond that?
Dr. Felice:
It’s everything you just said. I always have to say, being pregnant when you’re not ready and don’t want to be pregnant is a very big deal. I am totally in favor of birth control. I just feel everyone needs what is called informed consent. If they do go on birth control, there are certain better choices than others. They need to have a full array of options. Then they can choose. What do they feel is their best option at that time? Understanding potential pros and cons.
In terms of approaching women with PCOS, it’s a global lifestyle program. You have to deal with everything that you mentioned and more. You have to lower exposures as much as humanly possible to all kinds of chemicals in cleaning products, personal care products, air that we breathe, water that we drink. It comes off of clothing that we wear. There is nothing we can do to make us live in a pristine world. That’s not gonna happen. But we have to try to make the best choices that we can to lower our toxic exposure, to lower what is called our toxic load. Then, to do everything we can to improve gut and liver health, how most of these toxic chemicals get eliminated from our bodies.
There are other things we can incorporate, like saunas, which are helpful. Hydration, because we do also eliminate through the kidneys. There are a variety of things we can add on. But the primary is healthy liver, healthy gut. We deal with that by doing certain- We call that in my office a reset, or others call it a detox. It’s giving supplements and food that will support healthy gut integrity, gut function, and healthy liver function, to help the liver do its job. We can’t actually eliminate toxins by anything that we do. What we’re doing is facilitating our own bodies to do the best job that our bodies can do to eliminate the toxins and lower the toxic exposures.
We have to work on our Circadian rhythm by going to bed at a reasonable time and trying to go to bed and getting up at the same time. Sleeping in a very dark room so that we can have the optimal production of melatonin, which has been shown to have receptors on the ovaries. The melatonin that a woman produces at night while she is sleeping is optimizing her ovarian health and fertility, thereby her metabolic health. Getting adequate sleep is so critical. Like I said, a dark room. I wear a sleep mask because there is too much ambient light coming in my windows, and doodads that have lights in my bedroom. I like a sleep mask. They come in very comfortable designs, so everyone can find one that is agreeable to them.
Trying to avoid blue light. Ideally, none for a good two hours before you go to bed. If you absolutely must, then get blue light-reducing glasses to try to reduce the exposure. Try to do other things before you go to bed like take a relaxing bath or shower. Listen to podcasts or audiobooks. Play board games with someone you live with, like Scrabble or Bananagrams. Read a paper book or magazine. Those things still exist. Try to stay off of devices as much as you can for a couple of hours before you go to bed.
Take some time to do some exercise if you can. Any movement is better than no movement. Fitness is a vital sign. Exercise is medicine. Fitness and exercise play a huge role in everyone’s health, definitely in women with PCOS.
Eat a whole food, plant-focused diet. Predominantly eating plants, lots of different vegetables, colors of the rainbow. Eat some fruit. Don’t go crazy overboard. Try to have a lot of servings of vegetables and some fruit every day. Go as much as you can organic. I know it’s hard and impossible to be 100%, but as best you can, choose organic. Try not to eat too much animal protein, which is a little harsh on the digestive system. Try to keep it to three ounces or so.
If your gut is not SIBO, another topic, then you should try to eat a lot of fiber foods. Fiber is the food for the gut microbiome, which is disrupted. The first study of this came out from China: Women with PCOS have an abnormal gut microbiome and have impaired gut barrier or leaky gut. We have to work really hard to nurture our gut microbial population, those trillions of microbes that are essential to every health function of our bodies. The way that you nurture them is with plants and lots of them, and high fiber foods that they love. They will love you back. They will help you maintain a proper weight and feel good and have good brain function, good mood. We now know it’s linked to everything in the body, having the right microbial population or gut microbiome. I love plants.
Eat diversity. Lots of colors. Nuts and seeds. Whole grains can actually help you lose weight and lower insulin resistance, like buckwheat or millet or quinoa. They are not powderized. They are not milled. The whole grain itself. Resistant starch, like cold potatoes, can actually also nurture your gut microbiome, and they won’t raise your blood sugar.
The other thing that is so critical now, and this is very trendy but appropriately so, is time-restricted eating, or intermittent fasting. It’s really important for everyone, particularly for women with PCOS because they live a naturally jetlagged life because of not having their Circadian rhythm innately right. You have to do everything to try to work through our peripheral clocks. Every organ has cells that have their own clock genes. By eating in a timed way, you can actually help properly set the Circadian rhythm, so that all the organ systems of the body will be working in the same time zone, which is really important for overall health.
By timed eating, try not to eat more than three times a day. Try to have at least a 12-13-hour fast from dinner to breakfast. Try to have your first meal by two hours after you’re awake. Try to eat more of your food in the first part of the day when we’re most insulin-sensitive. Our digestive tract works the best in the first half of the day and goes on strike as the night progresses. That’s why people who eat late at night often have heartburn, indigestion, and so on. Eating late at night is really prevalent. Especially women with PCOS tend to have a disrupted appetite system and often want to eat at night. That’s the worst thing you can do.
You have to work really hard to get into the habit of trying to eat more food in the first half, and then stop eating at least three hours before you go to bed. Have about a 13-hour fast until breakfast. All of this can work dramatically to improve the health status of women with PCOS.
Dr. Eric:
With any health condition, you want to take a whole body approach. It seems like there is no exception with PCOS. Appreciate you sharing that.
As you know, most people listening to this podcast have thyroid or autoimmune thyroid conditions. One question I wanted to ask is is there a relationship between thyroid and PCOS? One connection I can make is with the disruption of the intestinal barrier. At least with autoimmune conditions, you have that leaky gut component. Having PCOS in that way might predispose someone to an autoimmune condition such as Graves’ or Hashimoto’s. I don’t know if there are any connections you are aware of.
Dr. Felice:
You hit it right on the head. That is the main one. After that first study came out of China in 2015, multiple other studies have come out, showing consistently that women with PCOS have in fact impaired gut barrier/leaky gut, the wrong gut microbiome, or dysbiosis. That definitely is a precursor to autoimmunity.
We know that Hashimoto’s thyroiditis is the most common autoimmune. Women with PCOS have substantially higher incidence of Hashimoto’s, or autoimmune thyroid disease, than the average population, which is high enough as it is, as I’m sure all of your listeners are aware.
This is a big deal because a lot of conventional doctors are not even screening for the antibodies for thyroid. Anti-TPO, thyroid globulin antibodies. They just get a TSH. They are missing the whole picture of what’s going on in women with PCOS. This is really important because this is critical for overall health. You talk about thyroid all the time. Thyroid hormone has receptors everywhere. It’s critical for every metabolic function in the body.
Here’s another interesting fact: Estrogen, in the form of estradiol, when you have a normal menstrual cycle, and the estrogen levels in the first half are rising, and then spike, which creates ovulation, that upregulates or turns on and makes more functional thyroid hormone receptors. Without adequate estrogen present, women will often have symptoms of hypothyroidism, even if you test the levels in the so-called range.
They have symptoms of low thyroid because once again, it’s not just having the hormone. It’s having it work properly on the receptors to create the effect in the cells. When you don’t make enough estrogen, then you’re not going to have proper thyroid receptor function.
That is an extra problem for women with PCOS. Even the thyroid they’re making isn’t working optimally. This is a huge deal. Thyroid is so critical for everything: for heart function, for brain function, for metabolic health, for reproductive health. This is such a big area that every woman with PCOS needs to have a very comprehensive workup of her thyroid tests. Looking at the gut to repair the gut.
Of course, it’s so complicated. The whole thyroid story is so complicated. You can’t properly convert from T4 to T3 if you don’t have a healthy gut and liver and have all the right nutrients on board, which means you have to have proper digestion, which is often impaired.
Thyroid is a huge issue in women with PCOS. I’m so glad you brought that up.
Dr. Eric:
I had to bring it up since this is the Save My Thyroid podcast, so I wanted to pick your brain. With testing, you’re absolutely right about doctors not doing a full thyroid panel along with antibodies.
When it comes to testing for PCOS, with all your patients, do you do all the sex hormones and the pituitary, FSH, LH, SHBG, insulin? Pretty much does everybody get the work in your practice?
Dr. Felice:
They do. I love data. I’m good at guessing, but I’d rather have data than just guess. In women with the mainstay form of PCOS, they will have a high LH to FSH ratio. Their LH is going to be produced in really high amounts because the brain says, “Make more estrogen,” so the precursor is testosterone. The LH goes up.
There is a problem with the FSH, which we don’t even fully understand. The FSH receptors don’t seem to be working well. The production of FSH from the pituitary gland is also inadequate. There is not a problem with the feedback system. You get too much LH and not enough FSH. That’s a very classic finding, to have what they call a high LH:FSH ratio.
You always want to check prolactin. Prolactin is a hormone that the pituitary gland makes. If you have too much prolactin, that itself increases androgen, or testosterone production, and the androgens from the adrenals, which includes testosterone.
You have to do a workup to do the rule-outs. I have said that PCOS is a syndrome. There can be other etiologies besides the mainstream, mainstay one. That is a diagnosis of exclusion. Everyone out there who has PCOS or thinks she has PCOS needs to know this.
You have to go to a doctor who rules out that you have an adrenal tumor, or what you have is something called acquired or late onset adrenal hyperplasia, or you have a pituitary tumor producing too much prolactin. There are things you have to rule out. When you rule out those things, you’re left with the more standard type of PCOS. It’s really important to understand to a significant degree that because PCOS is a syndrome, and it’s based on findings and symptoms. You need to rule out the other causes of those same symptoms that would have a different treatment approach.
Dr. Eric:
Makes a lot of sense. You shared so much valuable information. I could talk about this for another hour. Before wrapping up, is there anything specifically that I didn’t ask you that I should have asked you? Any last words that you have?
Dr. Felice:
I think the message I want to make sure I leave everyone out there with is a message of hope. When I describe what goes on, I know it can be overwhelming, and it sounds so negative. I want you to know that honestly, through lifestyle changes, that alone, just changing what you eat, when you eat, exercise, sleep, working on stress. We didn’t have time to talk about mind/body practices and stress. Discovering what your thyroid is like, treating it as necessary, and so on. When you actually make lifestyle changes, you can have unbelievable transformations in the body.
I’m not getting into pharmaceuticals. There are some appropriate uses of pharmaceuticals that I call “a bridge to health,” which can help to slow down a lot of the progression and reduce symptoms in a very safe way while you work on healing the body. Sometimes, I have to give hormone therapy in terms of giving human bioidentical estradiol and progesterone. It’s one of those catch-22s. You have to give the hormones to allow the body to heal. Once it heals, you don’t have to give the hormones because it will make them so much better and naturally by themselves. Sometimes, you have to give drugs to slow the production of testosterone.
I’m an MD. I will prescribe drugs when they’re needed. I always look at the safest, most efficacious approach. What are the risks and benefits of every drug?
I want to leave a message of hope. If you have PCOS, there is so much that we know now that I didn’t know back when I was trying to figure out what was wrong with me. You can get your life back. You can have a beautiful life. Don’t give up. Keep working ‘til you find the right person to help and work with you.
For people who want to learn more, I wanted to share that I have a health summit that is coming out right after Thanksgiving, November 28-December 4, being produced by Dr Talks. It’s The PCOS SOS Summit. I’m the host, and I interview about 50 experts in the field. We cover so many aspects of PCOS that you will eat up.
I want people to know this is available. It can be purchased, but it doesn’t have to be. It’s available for free online. Anyone who signs up can access it. If you go to DrTalks.com, you can sign up. If you go to my website, you can find it as well.
Dr. Eric:
Where can people learn about your books or buy your books? Amazon. Can you also mention your website?
Dr. Felice:
Sure. My website is named after my medical practice, which I am in. This is a converted exam room. I have an exam table over there. This is my makeshift studio. It’s called TheIntegrativeMedicalGroup of Irvine. It’s a brick-and-mortar practice. I see patients all the time. I can also do telemedicine. My website is IntegrativeMGI.com. for Medical Group of Irvine. I hope you will come and visit me. Maybe I can help you.
Follow me on Instagram. I try to post reasonably frequently. I wish I could get time to do more. My Instagram is Dr.FeliceGersh.
My books are available on multiple sites. The easiest of course is always Amazon.
Dr. Eric:
Wonderful. Thank you again, Dr. Gersh. It was a pleasure chatting with you about PCOS, talking about estrogen. Thanks for tying it into thyroid health. I’m sure my listeners learned a lot. I did as well.
Dr. Felice:
My pleasure. Anyone who needs me, just let me know. That’s my mission: to help women with all sorts of problems. Thank you so much for inviting me on.
Dr. Eric:
Thank you. Definitely visit Dr. Gersh’s website if you need a consultation, or again, if you want to check out her books. Definitely register for her summit.