Well Woman Podcast - Hirsuitism and PCOS

Dr. Frances Pitsilis hosted an episode of the Well Woman podcast focused on hirsutism and polycystic ovarian syndrome (PCOS). She discussed the prevalence and impact of excessive hair growth, explaining the difference between normal and abnormal hair patterns and the various causes including endocrine conditions, medications, and underlying health issues. Dr. Pitsilis outlined treatment options including hormonal therapies like the contraceptive pill and spironolactone, as well as natural remedies and hair removal methods. She also explained the concept of estrogen dominance and the benefits of natural progesterone treatment compared to synthetic progestins. The episode concluded with a detailed discussion of PCOS, its symptoms, diagnostic considerations, and comprehensive treatment approaches including dietary changes, nutritional supplements, and medication management with metformin and progesterone.

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Transcript

SPEAKER_00 0:03

Hello and welcome to the Well Woman podcast with me, Dr. Francis Pitsilis. Always deal with your healthcare professional and use this information for education and entertainment. Today I'd like to talk to you about Herseutism or hairiness and also polycystic ovarian syndrome. And I'm going to share the screen and uh use some slides today. Um, Herzutism, polycystic ovarian syndrome, and hormones. Everyone watching this or listening to it will know someone who has a problem with this and can have acne when they've got polycystic ovarian syndrome that hasn't gone away after their 10 years andor might have fertility issues, which is why the PCOS is important to pick up if there's some fertility problems. Excessive hair is one of the most common endocrine disorders that we know about, and it affects around 10% of women. And it's important not to miss an important medical cause and not just allow young women to be going to the laser clinics and just having it all removed without perhaps checking that there's not an underlying cause that is important to identify and treat. So this is an example of excessive persuadism or excessive hair. The pattern is not in the usual pattern. So the definition of it is radical versus pathological patterns. The hair distribution in normal hairiness that's racial is the same distribution that's normal, but just a bit more. Whereas abnormal hairiness shows increased hair distribution on the face, neck, abdomen, as well as other areas like the back. Now, when this abnormal hairiness is present, it's important to start looking into it. So here's another example if you're looking at the video. This is excessively abnormal hair on the abdomen. So what are the causes? Well, there are a percentage of people where no cause is found, and doctors call that idiopathic. I've mentioned racial. So there are some races like Mediterranean, Indian, and Middle Eastern women, where this is actually quite normal but it's in the normal pattern. Endocrine conditions, menopause. When you're before, during, or after menopause and there's a hormonal imbalance, this can be present. Polycystigovarian syndrome, underactive thyroid. The reason it's important not to miss an important cause is because excessive hairiness in the wrong area could be related to tumours of the ovary, the pituitary, or the adrenal glands. Another cause is excessive testosterone from a tumor or an endocrine problem, or perhaps the patient is using too much testosterone. And then you need to also think about insulin resistance, and this occurs in diabetes, polycystic ovarian syndrome, and excessive insulin causes excessive androgens or male hormones. Well, other causes include head injury, and this is um unusual. It's usually where you've hit your head that you get excessive hair, and it's a phenomenon related to the head injury. It's important to consider drugs. Now, phenytoin is still used for epilepsy, and this can cause increased hairiness. Danazole used to be used quite a lot for endometriosis, but not so much now. Stress can cause excessive hairiness, rare inherited chromosomal conditions, metabolic disorders, and this is the insulin resistance that's part of it, and rare enzyme deficiencies. So if there's a suspicion of an abnormal hair pattern or even a poor response to treatments, that person needs to be referred for further investigations. Now, um, for those who are listening, I'm showing a simplistic diagram of the hormones. Pregnenolone is the first step from progesterone from cholesterol. Our body makes our hormones from cholesterol, and pregnenolone is the first step, and generally off to the left, progesterone and then cortisol, and generally off to the right, DHEA, male hormones, testosterone and estrogen. But testosterone can turn excessively into dihydrotestosterone, and that what that's what can happen in polycystic ovarian syndrome in older women who have excessive enzyme activity there and in some other situations. So what's important is to identify and then correct the underlying cause of the problem. Commonly used, and this is generally speaking, the contraceptive pill, especially if the person doesn't want to conceive, it's convenient. And the contraceptive pill causes an increase in sex hormone binding globulin, which binds to the androgens, and that's how the contraceptive pill helps. And the next thing is spironolactone, which reduces androgen production. Spironolactone is a potassium-sparing diuretic, and it can also be used in blood pressure reduction. And another treatment is finesteride, and a brand name is propecia. And this blocks the enzyme called 5-alpha reductase, which converts testosterone to dihydrotestosterone. Now, a side issue with excessive testosterone, especially if it's turning into dihydrotestosterone, is that women can end up getting more hair on their face, neck, and body, but they could start losing hair off their head because of this enzyme. Now there's another medicine called cyproterone acetate, which is used on its own or within contraceptive pills, and this is an anti-androgen, which blocks androgens. Another approach is to use insulin sensitizers like metformin. And metformin you've heard about already on this podcast and all the wonderful benefits that it has. And it's very beneficial in polycystic ovarian syndrome and diabetes because it helps insulin resistance, it helps weight loss, and it helps bring back the cycle and those who haven't got a cycle or an irregular cycle. Now, if the person's been on any of these medicines and then stops them, they need to be prepared that they might get more hair growth and the benefits of the medicine will be reversed if they stop the medicine. So here's a diagram. I'm sorry that it's a bit blurred, but it's showing the four-ring molecule of testosterone and the enzyme 5 alpha reductase that's turning it into 5 alpha dihydrotestosterone. So what are the natural therapies if you don't want to have drugs? Well, natural blockers of 5 alpha reductase include zinc, evening primrose oil, soy foods, flaxseed oil, and progesterone. And you can also use omega-3 fish oil, which helps to reduce inflammation, and that there are natural supplements that reduce insulin resistance and can lower blood sugar. And they include vitamin C, chromium, magnesium, zinc, and other things. Of course, with the excessive hair, you need to think about how you can get rid of that in the meantime. And there are various things that people have tried and done. They've tried bleaching the hair with hydrogen peroxide, but it's not necessarily suitable for very hairy people. Plucking can cause irritation, as can waxing. Shaving can be useful if there are not many areas, but it might be difficult if there are large areas. And of course, there are chemical depilatories, but these can cause irritation. Electrolysis might be suitable for small areas, but depending on the person who's doing it, it may cause scarring. Laser therapy and IPL, intense pulse light therapy, has been found to improve depression and anxiety in women who've had this treatment for excessive hair, and it's commonly used these days. So, what you need to know about laser and light therapies for hair reduction is that no laser or IPL can permanently remove your hair. You need to remember that you need a course of treatment, and by the end of your course, you will achieve about 85% eradication at best. Be careful with the clinics out there. Anyone claiming permanent hair reduction is actually misleading, and you need several treatments to get to the 85% hair reduction, and then you need to be aware that you need to go back every few months to push back or knock back any new hair follicles that are developing in the meantime. Now, I want to talk to you about estrogen dominance. I've mentioned that previously when I was speaking about progesterone, and it's very, very common that instead of getting a nice boost of progesterone in the second half of the cycle for various reasons, for example, polycystic ovarian syndrome and endometriosis, and in women who are stressed or approaching menopause, that boost of progesterone in the second half of the cycle is not there. And so you become estrogen dominant. And where that is worth knowing about and understanding it is that there's that that can be dealt with, that you can support the low progesterone in the second half of the cycle. Sometimes overdosing with estrogen, as in the case of the early stages of menopause, can also cause problems. These are women who have had a hysterectomy and they're given estrogen without progesterone. But the general sort of symptoms of estrogen dominance, which polycystic ovarian syndrome sufferers have, includes fatigue, breast tenderness, premenstrual syndrome, fluid retention, headaches. If you have got periods, they can be heavy or painful, fibrocytic breast disease, utrine fibroids, mood swings, dry vagina, hot flushes. Yes, dry vagina and hot flushes are not just from low estrogen. They can be from low progesterone. Other symptoms include reduced libido, as I've mentioned previously, loss of scalp hair, anxiety, sleep problems, postnatal depression, acne, PCOS, and endometriosis. Let's talk about natural progesterone. It's made from soy in a factory or a compounding pharmacy and is the same as your body and it acts all over your body. It's named bioidentical progesterone or micronized progesterone. Now, before I move on, um in New Zealand until perhaps three years ago or so, women could only get the compounded product, but now they can also have access to funded utergestin, which is bioidentical but has a couple of additives, and that's why a small percentage of women might not tolerate it, and then they'll have to obtain the compounded progesterone. Now, how does natural progesterone compare with synthetic progestins that are used often in the contraceptive pill and in the past used quite a lot in hormonal replacement therapy or menopausal replacement therapy? These synthetic progesterines are not natural, they act only in the uterus and can give numerous side effects. And the short story includes bloating migraine depression and they can actually increase acne. So here's a diagram if you're watching, uh, comparing natural progesterone with synthetic progestins. We know that that manufactured bioidentical progesterone when they analyze it is indistinguishable from that that is produced in the human body, whereas synthetic progestines have got a different chemical structure and have side effects. So I've got a long list of side effects here if you're watching. Acne, lack of periods, backache, breakthrough bleeding, breast tenderness, change in weight, jaundice, decreased glucose tolerance, diarrhea, dizziness, swelling, fever, fluid retention, flushing, acid reflux, genital abnormalities, headaches, insomnia, irritability, jitteriness, lethargy, loss of scalp hair, depression, nausea, nervousness. Yes, pulmonary embolism, they can cause increased blood clot, respiratory depression, and seizure. So what's the side effect of natural progesterone? Well, if it's working well, people sleep well, they feel better, more relaxed, less depressed, and I've had some patients tell me that they become too relaxed. So that's a side effect, and I have to reduce the dose. I tend to get side effects mostly with the uterestan in a very small percentage of women. So this is generally very well tolerated. So what are the benefits of natural progesterone? Protects the uterus lining, protects breast tissue, increases metabolism, promotes weight loss, reduces blood sugar, gets rid of fluid retention, normalizes blood clotting, stimulates bone production, promotes normal sleep, reduces migraine, helps thyroid, reduces depression and anxiety, improves libido, maintains pregnancy, and balances the side effect of excessive estrogens. So that's the estrogen dominance that I was speaking about. So let's talk more specifically about polycystricovarian syndrome. It is the most common endocrine disorder of women. 12% of women are diagnosed with this problem. And the two main problems associated with this are too many androgens and insulin resistance. So you tend to see hairiness and acne, but also overweight, irregular periods, and infertility. There are, however, women who are slim who can have this, and this is where it can be missed. And it runs in families. So you tend to have infrequent or no periods, signs of too many androgens, acne, Hirchitism, excessive hairiness, or abnormal blood results, increased testosterone, increased DHEA, and where it's funded, increased dihydrotestosterone. This is not funded, this last test in New Zealand, but you can get clues from the increased DHEA and the increased testosterone. Now, when you're dealing with this, you need to exclude other problems that are causing these symptoms. And you don't always see cysts on the ovaries. So diagnosing polycystic ovarian syndrome can be difficult. So what are some of the other symptoms? Inability to lose weight, fatigue, constant hunger, sugar cravings, obesity, abnormal cholesterol. Yes, there's often a low thyroid with this problem. Um yes, polycystic ovarian syndrome is associated with insulin resistance and the risk of diabetes, heart disease, anxiety and depression. And a hidden uh underactive thyroid can be associated with this. And often it's not picked up, and um, if it had been picked up, it would have helped the acne and it would have helped the weight loss. So we need to look at the we can treat the acne and the herchatism, the hairiness in the usual way, but please note that really you need to look at the underlying causes. So blood tests can be done to make sure there's no pituitary tumour, as I mentioned previously, testing testosterone and DHEA, but also testing blood glucose, fasting insulin, hemoglobin A1C, cholesterol, liver function tests, because these patients can have fatty liver. And the fatty liver can be associated with the insulin resistance, but an underactive thyroid can be associated with the insulin resistance and with the fatty liver, and this is not always seen. You'll often see a raised uric acid, a raised CRP, or fibrinogen, which is an indicator of inflammation. You ultrasound the pelvis as well as these blood tests, but um, you know, be careful and always look at the patient and look at the symptoms and look at the features. Um, and if you're not sure you get an expert to have a look at the patient, a specialist. So, what's the treatment? Diet and lifestyle first. Um we'll talk about that. Then we correct imbalances, drugs last. Now, what's really an important part of all of this is the metformin and the progesterone. I will often see patients who've been given metformin but not the progesterone. So then I give them progesterone, which really helps a lot. So doctors manage client expectations and do investigations, but they have to refer when they're not getting anywhere, the hair distribution is abnormal, the acne isn't responding, there's abdominal fat present, if a diagnosis needs to be made and they're not certain, or and as I mentioned, if they're not responding to treatment. So the diet will really be a ketogenic type diet, um, highly plant-based, adequate protein, but keeping carbs and sugar low. Then you correct nutritional deficiencies, and I think everyone should have a good multivitamin with methylated folic acid in it, fish oil, and vitamin C, and then you can uh test and correct B vitamins, zinc, vitamin D. I make the diagnosis of low magnesium clinically. Um, just reminding you again that you can block five ale for reduct days naturally with zinc, evening primrose oil, soy foods, and saw pometto, as well as progesterone. Treat hormone imbalances. Uh, use the progesterone and I Identify the thyroid, remembering that the thyroid blood tests are not fully reliable, and you need to be suspicious about it. So the next part is, or the other consideration is the metformin. Why would we use it? Because it's very good at restoring regular periods. It reduces the androgens, helps weight loss, reduces fasting insulin, glucose, and lipids, reduces the hairiness, and it improves fertility by helping ovulation. It also improves endothelial function because it helps the heart and the vessels. So these patients with insulin resistance with a tendency to diabetes are at risk of developing ischemic heart disease, coronary artery disease, and having problems after that. So I've given you a comprehensive view of hairiness and polycystic ovarian treatment. And I'd like to remind you that the biodential progesterone is also used to help regularize the menstrual cycle, suppresses excessive LH from the pituitary, which causes too much androgen, helps ovulation, blocks 5-alpha reductase, and supports the second half of the cycle in fertility treatments. Now it's alright to use oral contraceptives as well as progesterone and metformin if you don't want to conceive. And in fact, when I give progesterone, I ask the patient to take the progesterone whenever they're taking the active contraceptive pill. So thank you for listening and watching. I hope you found this interesting. Maybe you could share this with someone that you know that's got these problems, and maybe they're interested in learning a bit more and then discussing it with their doctor. This has been the Well Woman podcast. I hope you can like and subscribe. And I look forward to seeing you at the next um visit, at the next podcast. That's it for me, and I'm out for now. Bye to everyone.