Dr. Shilpa P. Saxena adds to her series of Evolution of Medicine interviews with a discussion on polycystic ovary syndrome (PCOS). With both personal and professional experience reversing the condition, she walks us through the functional medicine approach to treatment.
Dr. Saxena explains how insulin resistance often accompanies and must be addressed through the “matrix” of each patient’s overall health and lifestyle. Since PCOS is a clinical diagnosis, she also describes the signs practitioners should look out for in their patients and how to confirm the diagnosis with the aid of laboratory testing.
Developing a niche in PCOS can be a great opportunity for practitioners since it is so prevalent, affecting between 6-12% of women, and because functional medicine provides the most robust treatment approach for complex metabolic conditions.
Listen to the full conversation to learn more about:
- Tailoring treatments to patients with PCOS
- Which supplements to utilize in a PCOS treatment protocol
- Common root causes and co-conditions
- The importance of securing Phase I and Phase II detox pathways
- How group visits can be a powerful aid to treatment
James Maskell: Welcome to the Evolution of Medicine podcast, the place health professionals come to hear from innovators and agitators leading the charge. We cover the latest clinical breakthroughs in health technology, as well as practical tools to help you transform your practice and the health of your community. This podcast is brought to you by the Lifestyle Matrix Resource Center, who provide a range of options to help you deliver successful, effective, functional, and integrative medicine. To find out more and to get started, go to goevomed.com/lmrc. That’s goevomed.com/lmrc.
Hello and welcome to the podcast. This week, we are going to be talking about a specific clinical condition through the lens of functional medicine. We’re going to be talking about polycystic ovary syndrome. And this week, we have on the podcast Dr. Shilpa Saxena. You’ve probably heard her. She’s been on the Evolution of Medicine a number of times. She’s the creator of the Group Visit Toolkits. She lectures around the world on functional medicine. But in this case, she is actually someone who had polycystic ovary syndrome, and so knows it inside and out.
This is part of our continuing commitment to just bring you the best clinical content, to just bring you sort of foundational science, but then also strategies from the front lines, and how to get better outcomes with your patients. So very much look forward to hearing your feedback on the session. Enjoy.
So a warm welcome to the podcast, Dr. Shilpa Saxena. Welcome back, Shilpa. Great to have you back.
Shilpa Saxena: Thanks, James. Always great to be with you.
James Maskell: We’re excited to just keep the momentum on great clinical topics on the Evolution of Medicine Podcast. And I can think at one point we were just going back and forth to talk about some of the things that you talk about regularly, like heart disease and type 2 diabetes, and the things that you are on the circuit talking about all the time. But I guess one of the conversations that came up was about PCOS, polycystic ovary syndrome.
And I guess we sort of had a feeling that this was something we hadn’t really talked about on the Evolution of Medicine podcast before and could be helpful. And also, that it’s related to the other things that you’ve spoken about before. So, I guess, let’s just start with the sort of basics. How prevalent is it? Who gets it? And which populations are more at risk?
Shilpa Saxena: So, there’s probably six to 12% of US women that are affected by PCOS. That’s around five million women. And an impact of PCOS, not for all women, but for many of them, is infertility. And having been a PCOS patient with a history of infertility myself, I just know that that occurs just as powerful and negative as a cancer diagnosis. The ability to be able to have children in a biological way is a huge death sentence for some women. And they have it that this is just a disease I’m stuck with, and I’ll take drugs.
And so, the populations that tend to be at risk are those that are at risk for insulin resistance, inflammation and stress disorders because those are the main things that drive PCOS. The other thing that I would… So, women, especially if they have a family history of diabetes, if they have a sibling with PCOS or insulin resistance, these things live in genetic families. So PCOS is just a cousin of diabetes if you will.
James Maskell: A cousin, okay. So, are the causes the same of that as diabetes? What are the typical root causes from your sort of functional medicine lens, I guess?
Shilpa Saxena: We always say in functional medicine a lot of the upstream causes are the same. So, yeah, inflammation, insulin resistance and toxicity, those things… And inflammation breaks down to poor lifestyle, chronic co-infection, stress, but it boils down to inflammation, insulin resistance and toxins for many people.
James Maskell: Okay. I want to dive deeper into, I guess, the insulin resistance piece because, I mean, I’ve seen research that says that 70% of women with PCOS also have insulin resistance. So, I guess, how would you recommend, or how would you think that could affect the sort of standard of care knowing what we know? If we know that, how should we be thinking about the standard of care with regards to PCOS?
Shilpa Saxena: Well, obviously, we should be screening for insulin resistance for anybody who shows up with the clinical criteria for PCOS. Just as a reminder, PCOS is not a lab diagnosis, it’s not a radiology diagnosis. It’s a clinical diagnosis. So, if you start seeing women who present in the pattern of irregular periods, if they’re hirsute, if they have this altered body composition, just things that make you think PCOS 150,000 percent, you should screen for insulin resistance. I mean, 70%, and I would say some research says it’s almost universal in women with PCOS to have insulin resistance.
James Maskell: That’s really interesting. Well, I guess, how would you know if it is causing it? What kind of testing would you do to identify that?
Shilpa Saxena: You can start with the traditional tests, fasting blood glucose. Of course, we can add in a fasting insulin. We can do a two-hour glucose tolerance test or a two-hour insulin tolerance test. You could get a hemoglobin A1C. You can also get a C-peptide. So certain companies have a metabolic insulin resistance score that you can get. So, there are many different ways that you can kind of look around the PCOS patient and get clues.
Obviously, we don’t want to forget that there’s physical exam findings, like acanthosis nigricans, the darkening of the folds or behind the neck or in the armpits or in the groin, skin tags. Just like I said, the body composition when they have more of that apple obesity. You don’t want to use one number as like the binary reason somebody has it or not. We really want to look like a matrix. Like, does this person act and look… If it acts like a duck, quacks like a duck, looks like a duck, it’s probably a duck. But if you get a test that says it’s a zebra, but everything else points to duck, go with duck.
James Maskell: It’s really interesting you say that. So, I was in London a few weeks ago, and I had dinner with Dr. Ayan Panja and Dr. Chatterjee, and they were saying that their favorite functional medicine lecture of all time was Michael Stone’s lecture on the nutritional body intake. Looking at the body and looking at all the different ways in which nutrition shows up. And sort of the like the old school doctoring ways that maybe have been forgotten. And it seems like, I guess, what you’re saying there is that there’s a need to really take a more holistic viewpoint than just the lab tests that show up.
Shilpa Saxena: Yeah. Labs should confirm your diagnosis, but you should use your history, physical exam to really, again, make sure: Is this a duck or a platypus?
James Maskell: It’s so interesting. I haven’t thought about polycystic ovary syndrome for a long time, but I do remember, in 2011, I got my first kind of talk as a practice management guy. And I was speaking to third and fourth year students at Bridgeport University in Connecticut. And I went up to meet with them and talked to them about, what is the potential of sort of social media in the future of medicine? Because, ultimately, that was 2011. Social media was kind of new.
And I said to them, “Look,” and I guess what I was drawing from at that moment was, I was sort of sharing that, “Your best pathway to success, if you’re starting your new practice from scratch, is probably to be an expert in one thing. Because there’s so many conditions that come through, especially if you’re a naturopathic doctor or primary care. You’re seeing so many different types of things. The best pathway to success would be to be an expert in one thing, and then you could grow from there.”
And I remember saying like, “Someone’s going to be the functional medicine expert in polycystic ovary syndrome.” And I just drew that out of my head. I don’t know why I said it, but I remember saying it. I think it’s on audio somewhere because I audio recorded it. And it’s so interesting, all the things that you’re saying. I mean, you can imagine… I think now, what, 11 years later, there’s probably 10 podcasts that are just on PCOS. As people have started to realize that, okay, women who go to their doctor and get a PCOS diagnosis will start to look outside of the box for information.
And if there’s someone out there who’s talking about the root causes, talking about insulin, talking about the right kind of testing, talking about how you would know and things that you could do, obviously, that’s a great opportunity for practitioners to build a niche. But it sounds like if you were a PCOS specialist, you could end up being a diabetes and blood sugar health specialist just as easily because a lot of the information is coming similarly, right?
Shilpa Saxena: Absolutely. And then there’s as much as PCOS is a lot like diabetes, it’s a cousin, but it also has its own world of specialized interventions and needs. Just like if we’re taking care of children on the spectrum, they’re children, but they have specialized needs that, when you have someone who specializes in it, they can dig deeper into the granularity of those things. So I think that makes great sense, especially with almost one out of 10 women being affected by this.
And I do believe it’s going to get worse over time because our lifestyles aren’t improving. You see these young girls getting precocious puberty. They’re experiencing stress levels that are beyond what you and I likely experienced at their age without social media and without some of the other new aspects of stress development. So, I think just like obesity and just like fatty liver disease, which are also cousins of diabetes, PCOS is going to be on the up in my opinion. So, we need people who are educated to help these women.
James Maskell: Well, good. Well, I want to get into those lifestyle modifications and that kind of stuff as we go along. But I guess one question I had for you: Is there a link between COVID-19 and PCOS? Is there something that’s driving that?
Shilpa Saxena: What I would say is… If we know that PCOS is driven by inflammation, insulin resistance, and toxins, well, then we’ve just got to look at COVID-19 as a hyper-inflammatory state. We know that when people get a COVID-19 infection, their coagulation goes up, inflammation goes up, and inflammation then drives the insulin resistance. So, if you have a gene for PCOS or insulin resistance, and then you just kind of stoke that fire, that genetic fire with COVID-19, you could flip somebody into PCOS, for sure. So, in the sense that COVID-19 increases inflammation, it’s a driver of PCOS.
James Maskell: Interesting. And obviously the sedentary lifestyles and other things that came as a result, not of the virus, but, obviously, of the public health plan contribute to it as well. So, let’s get into it. So, a patient comes into your office, and they have PCOS. Where are you starting with regard to the bottom of the matrix? What’s the most important as a sort of a foundation before you would get into individualized care, I guess?
Shilpa Saxena: So, the entire bottom of the matrix we want to look at number one: diet. We want to go to an anti-inflammatory diet. You can always start with a Mediterranean-type diet, a cardiometabolic, low-glycemic, I would say low-gluten impact kind of diet as well, too. So, we want it to be rich in phytonutrients because we want to quell inflammation, decrease oxidative stress. The other way we can decrease inflammation is exercise/movement. So, not being sedentary and then putting in some structured exercise.
But the other big driver of PCOS is the HPA axis, the hypothalamic-pituitary-adrenal axis. So, women that are genetically predisposed to PCOS, some of them have like this hyper-functioning HPA axis where, when that gets activated from perceived stress, cortisol increases and that cortisol drives the insulin resistance. And it’s almost as though, epigenetically, when a woman is stressed, the body decides to put out more male energy, which is androgen production. It’s like a survival mechanism, but people with PCOS do it too much. And that’s what creates the imbalance for fertility.
James Maskell: Wow. That’s really interesting. I hadn’t thought about that. It’s interesting when it, when we sort of get into, I guess, functional medicine and talking about it, you always have the baseline of lifestyle medicine, so you have to get that done. But ultimately, what it typically looks and why functional medicine, I think, sits on top there, is that there are these systems biology considerations that you have to really understand if you want to get to the root cause of it.
And I would imagine… I guess, can you talk us through, if you had a case of PCOS, in what order would you go about unlocking this? You get the lifestyle stuff going first. You start to look into systemic factors. You start thinking about the HPA axis, the gut. What are different things that you are looking for as you start to sort of get beyond the lifestyle, into this sort of systemic stuff?
Shilpa Saxena: So, having been trained primarily through the IFM timeline matrix model, I take a great history to understand like, “Hey, what’s been the life of this person.” When I’m doing that, I’m creating partnership, but I’m also understanding like, “Hey, what’s the kind of stuff that this person is likely willing and open to do?” So, for example, even if I think exercise is the greatest thing that could help this patient, if they’re not somebody that seems open to it or has the circumstances to allow it, why start with something that they’re not going to be able to accomplish? So, you want to get to know the person to know, “Should I offer diet, exercise, stress management?”
Because they’re all powerful, but the one that they do is going to be the most helpful. So just remember that. You’re treating a person; you’re not treating their condition. They just happen to have a condition. You got to know their circumstances to know which one to start with. So therapeutic partnership and prioritize the recommendations based on what you think they can or are willing to do. And, of course, what you have access to support. You might be really, really great at diets, and you have all these handouts, and you can do a great job. Start there.
But the other thing that I think is critical from a functional medicine perspective is to clean up the microbiome and their liver detoxification pathways and get them, don’t be surprised I’m going to say this James, pooping. So, the pooru speaks, as James and I—
James Maskell: It’s like a broken record.
Shilpa Saxena: I can’t help but bring in bowel movements to any conversation. I apologize. But estrogen dominance is a common systems biology dysfunction in PCOS patients. And we primarily get rid of excess estrogen by having a healthy liver and a healthy colon elimination pathway. So, you’ve got to make sure they’re getting rid of excess hormone appropriately. And then you are working on lifestyle, you’re reducing inflammation at the level of the microbiome by doing the 5R approach, taking out the infections, the food triggers, putting in probiotics, putting in glutamine, and all the nutrients you need to seal up the leaky gut, if it’s there. Reduce inflammation, so we’re decreasing that burden and we’re hopefully going to turn the gene off by taking away its fuel.
James Maskell: That’s really powerful. I get that. So do you, is there a typical… Are there supplements that you have found to be most useful for this condition? Or does it really depend on what you find when you go in for the root-cause analysis?
Shilpa Saxena: Well, I think, like I said, you always want to do your go-to microbiome rehab supplements that you have. Then I really recommend that you make sure that they have great phase I and phase II liver support, and make sure that they’re pooping, whether you’d use magnesium or aloe or whatever you’re using to make sure that they’re eliminating. And then, if you wanted to specifically start targeting the insulin resistance, think of things like alpha-lipoic acid and vanadium, berberine is wonderful. NAC is wonderful. So, we’re hitting inflammation, oxidative stress, insulin resistance, resveratrol, acetyl-L-carnitine.
I mean, there are so many things. And what I really like is using companies that use blends to be able to help insulin resistance. Because I don’t know about you, James, but I don’t want to pop 50 pills every morning. So, if it could be in a blend or if it could be in a shake, that makes me feel like I’m less sick. If I don’t want capsule fatigue from pharmaceuticals, then I don’t want it from supplements either, if I can help it.
James Maskell: Absolutely. That’s such a good point. I guess, I would love to just talk about the weight side of this too because I know that, typically, there’s this sort of weight gain association with it. And where does that come from? And how do you end up sort of dealing with that? And in what order should you deal with it? And what are some tips that from the front lines on empowering patients to participate when weight is a sort of a side effect of the clinical condition?
Shilpa Saxena: You’re right. It’s part of the vicious cycle. They gain weight from some lifestyle behavior maybe or some toxins. And then that drives their PCOS, which makes them more weight loss resistance, which drives their PCOS further, which then puts them into more weight gain, and it’s a vicious cycle. So what I think is, number one, I like to make sure I don’t put too much pressure on optimizing body composition on visit one. I think many women have been trying to do that.
Now, if they’re all gung-ho about it and that’s what they want to work on, great. Then we attack lifestyle. And I still work on microbiome and liver and elimination as my first go-to steps. It’s just that we say, “Okay, let’s see what kind of inflammatory fat leaves with just doing this.” I try not to make a number on the scale the goal because that starts getting into people’s heads and starts becoming stressful, which again will drive the PCOS forward.
So, we want to focus on prioritizing healthy behaviors and compliance with the supplements they feel like they can take and then just let the weight loss be a side effect. Now, at some point they might hit a plateau on their weight loss, and they still need to lose more. Maybe they’ve maximized their lifestyle and they’ve maximized what they think they can with supplements. There’s definitely some novel things coming out these days, like peptide therapy, that can help with weight loss.
Something that I think is sometimes better than the old school phentermine appetite suppressant. The semaglutide is the latest in peptide therapy that helps decrease appetite, but it’s working through an insulin mechanism called GLP-1. So, in my opinion, it’s normalizing what is the dysfunction using a little peptide string of amino acids.
James Maskell: That’s really interesting. Okay, well, look, I think that’s a pretty comprehensive overview, and I’ve seen a lot of innovation happening. I’ve seen more testing packages regarding this kind of stuff that get into the PCOS and then sort of a broader range of numbers. That’s all sort of in the metabolic space. I think that’s really interesting. But I can’t let you go without talking about the potential of groups for PCOS, and whether or not… Is this a diagnosis type where, if you run a family medicine clinic or a primary care clinic or a women’s health clinic or an OB/GYN clinic, that it would be reasonable to think that a PCOS group might be helpful?
Shilpa Saxena: Absolutely. Whenever you find a community of people that have a shared experience, shared struggles, shared potential for improving together, sharing best practices, just sharing space together, group visits make sense. And if you think about PCOS, it’s a painful diagnosis for many women, and it could be the nature for some women to want to come together and share their experience. And not only that but share information because, as you know, James, and groups, it’s not always the provider that is the deliverer of the great information. There are people in the group who are smarter than the provider many times on subject matters.
And so, you could just imagine that you could have a four-week group workshop for PCOS women, where week one, you talk about the issue. Week two, you focus on diet. Week three, you focus on exercise. And week four, you focus on stress or sleep or acupuncture or whatever else you want to focus on, but these women learn together. And it’s kind of the same principle that researchers who looked at Weight Watchers, the reason why Weight Watchers works is because of the group. It’s less about the app and the points and stuff like that. What they notice is when they do the same information on an app without the group, not the same degree of weight loss.
James Maskell: So, it’s not the shakes. I thought it was the shakes.
Shilpa Saxena: They help, but it’s the group. Because it’s the behavior change, right, James? We know that’s all it. It’s the behavior change that’s going to create the healing.
James Maskell: So, which one of the Group Visit Toolkits should you get if you are interested in helping people with PCOS?
Shilpa Saxena: Well, obviously, the one that’s related to protecting the heart, blood sugar, blood insulin level. And just one thing, thanks for bringing that up, James. You got to know that women with PCOS have higher rates of cardiovascular mortality because they’re driving their risks for diabetes-like illness at a young age. If you think about old school, people got diabetes in their 40s, 50s, 60s, so their heart disease risks was starting in middle age. But these PCOS women are starting in their teens with their, if you will, diabetic-like risks. So, these women have a risk for premature heart disease, and they have risks for early cancers related to their estrogen dominance and their hormone imbalance.
So, yeah, basic, we want to go into protecting the heart with the blood sugar, blood insulin. Then you want to protect their heart from the inflammation and the lipids. So we have that advanced cardiovascular prevention one. Then there’s one on losing weight and detoxification. That would be great. We have one on exercise. I mean, honestly, the things that are foundational in these group visits, we have one on the gut. You could pick from most any group visit and it would apply to PCOS. You just have to put a PCOS spin on it. Just kind of tailor the recommendations slightly to address your PCOS population.
But I also want to say, James, you could bring a PCOS patient with a diabetic patient, with a patient who’s trying to avoid Alzheimer’s, with a person who’s got fatty liver, put them all in the same group and teach them the same thing. They all just have different downstream expressions of the same root-cause drama.
James Maskell: It’s the different like links in the chain. It’s the different genetic expression from the epigenetic influence of the environment. I think that’s a great point. And actually, probably, a good shout out here for the Group Visit Toolkit and Lifestyle Matrix Resource Center that their new membership model would allow you to pull from different parts of all those different PowerPoints to create something. And yeah, just super grateful, again, Shilpa for you creating that for everyone who’s using it. And to, now, these next steps have been just such a big gap, I think, for practitioners to make it easy for them to educate and communicate and do it. So thank you so much for doing that. And thanks for sharing your wisdom here. Anything you want to say before we wrap up on this PCOS topic?
Shilpa Saxena: As a person who was diagnosed with PCOS at age 28 and was given the infertility label, I just want you to know that women in this group would be deeply appreciative for someone to take on their case from a functional medicine perspective. You give them their life. So as someone who now has two healthy, beautiful children, and I’m working to prevent PCOS from showing up with my daughters, I just tell you that you would be creating a legacy of good when you take on this issue. And just know that you don’t have to be an expert in PCOS. You’re already an expert in functional medicine and lifestyle. Take that on, and you will help these women.
James Maskell: Amazing. That’s such a great point. That when you help the women, the impact of it is really exponential because of their impact on the family and then the next generations. And it’s interesting as well, you mentioned with the infertility, because so many people who don’t know what I do or other people of having problems conceiving, and the first step when that starts to happen is typically IVF. But it seems there’s just so many steps that can be taken that are way less costly, way less invasive, and have a fair degree of success. So, it’s really exciting to hear that.
So, thank you so much for being part of the podcast. This has been sort of a short masterclass here on PCOS. Check out the tools from Lifestyle Matrix Resource Center. You can see, obviously, and hear from Dr. Saxena’s training, just how valuable that functional medicine training is. To be able to not just understand what are the foundations of lifestyle medicine, but what are some of the systemic factors that go into these chronic illnesses. And then applying that thinking to chronic illnesses. What we all need to be doing, I’m grateful for it, and the world is grateful. I know your patients are grateful. Thank you so much for being part of the podcast Shilpa, and we’ll see you again very soon.
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