Episode 11: PCOS SOS with Dr. Felice Gersh

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Hi, I'm Dr. Tabatha, the Functional Gynecologist. I'm a board-certified OB-GYN and functional medicine physician. I've embraced the world of functional medicine and wellness through my own personal health journey, and I'm super excited to share my wisdom and unique perspective as it pertains to women's health. So if you're struggling with hormone imbalance, weight gain, period issues, anxiety, insomnia, you name it, Then you've come to the right place. I want to be your functional gynecologist. So welcome. Today I'm honored to have Dr. Felice Gersh on my podcast. She's board-certified OB-GYN. She completed a fellowship in integrative medicine at the University of Arizona School of Medicine and is the director of the Integrative Medical Group of Irvine, California. She's awesome, you guys. She's internationally recognized pioneer in integrative women's health. She's the author of PCOS SOS: A Gynecologist's Lifeline to Naturally Restoring Your Rhythm, Hormones, and Happiness. In addition to her clinical practice, she frequently lectures on the role of the circadian rhythm in polycystic ovarian syndrome and its relevance to the microbiome, nutritional medicine, time-restricted eating, and fasting. We actually cover all these topics today in the podcast, so it's really awesome. You're going to just learn so much from her. Just some background information on PCOS. It stands for polycystic ovarian syndrome. About 10% of all women have PCOS, making Making it the most common endocrine disorder and the most common cause of female infertility in the world. Women with PCOS may suffer from acne, menstrual irregularity, infertility, obesity, autoimmune disease, diabetes, and heart disease. Traditionally, we doctors have silenced the symptoms with different medications, but that approach doesn't really address the underlying root cause of PCOS. So women are medicated but not healed. So be watching for an upcoming episode where we discuss PCOS in depth and the ways to tackle it at the root cause, whether it's problem with insulin resistance, inflammation, post-birth control syndrome, or adrenal gland-based PCOS. In Dr. Gersh's book, PCOS SOS, she shows women how to beat PCOS naturally, replacing pills with powerful and scientifically backed lifestyle interventions that harness the body's Capacity to Heal. So like I mentioned, she and I discussed these in detail. So let's dive in. Here we go.

Welcome, Dr. Gersh. Thanks for coming on The Functional Gynecologist. I'm so excited to be connecting with a fellow gynecologist who practices integrative medicine. I was reading your bio and I saw that after you did your traditional residency, you went on to do an integrative medicine fellowship. Way, you know, over a decade ago. What was the reason for that?

Well, I always knew that there was much more to helping women than the conventional with surgery and pharmaceuticals. So from very early on in my practice— and I started my own practice way back, I wanted to go on my own path— so I knew that there was more. And so I incorporated Chinese medicine practitioner, I had nutritionists, A psychologist, biofeedback, massage therapy. So I had a variety of what I called my ancillaries, but I had no specific training myself. And so there was a little disconnect. I would do all the conventional, then I would just refer them. And then it was after I gave up obstetrics, and that's now a dozen years ago, it seems. So the time just flies, as you know. And so, but when I gave it up, it was like a revelation as I had more time, maybe more sleep, that I really looked at my therapeutic toolbox as a gynecologist. And I said, this is pretty pitiful. Mostly what I have is surgery.

Right.

And I was very good at surgery. I taught surgery at USC to the residents, and I was on board with every new gizmo and gadget that came down the pipeline from the medical device manufacturers. But I also, because I was right there front line and center, I was disillusioned by a lot of these devices as well. I saw a lot of problems right from the the beginning of the use of these different products. And I reported them, nothing happened. So I just looked at all the harm some of them had done over the years to women before they were taken off the market or given black box warnings. And that applied to pharmaceuticals as well. It's like, wait a minute, my therapeutic toolbox is so tiny and there are so few pharmaceuticals that actually are very useful. And I said, what do I have to do?

And I've—

so I had this sort of crisis of purpose. It's like, I don't know what I'm doing. How am I helping women? This is not not being very proactive. I would say, when it gets really bad, we'll cut it out.

Yeah.

So that's when I went on my personal journey to try to find better solutions. I started taking functional medicine courses, courses with naturopathic doctors, every kind of course I could. And I ended up in the room at one of the courses with the only other MD. I'm an MD and she's an MD, and everybody else in that particular room was a naturopathic doctor. And I went up to her with Dr. Lodog, who was the director of the Integrative Fellowship at the University of Arizona School of Medicine. And I said, I'm just roaming. I'm a roamer. I'm just trying to find answers and I have no real direction, no real plan. I'm just running around trying to do things on my own. And she said, after talking to me, I'm qualified. Apply to come and do the fellowship. And it started in 2 weeks. So I went home. I was in Portland. I flew home that weekend. I did the application. 2 weeks later— You were in Portland? I was in Tucson, and I did the 2-year fellowship, which I completed. Now it's in 2012, so I started it a decade ago. And of course, like you, never looked back, only looked forward to gaining new skills and new abilities, new therapeutic tools to help women at every stage of life to optimize health. Because in this world that we live in, everyone needs a lot of help.

Yeah, that is wonderful. I kind of had the same journey. I, you know, I Yeah. Was in the conventional medicine world and doing a lot of surgery and prescribing a lot of birth control pills for all these different diagnoses. And women weren't getting better. Their hormones weren't getting balanced. They weren't losing weight. They were still ripping their hair out and feeling crazy, you know? And what do you think is the biggest challenge to getting women to realize that there is another way? There's lifestyle changes and your diet is so important. What would you say to women who've never heard of functional medicine before?

Well, first, to leave all your preconceptions behind. And that usually includes, like you mentioned, birth control pills. That birth control pills, which most women have been put on for a variety of reasons including contraception, but many other reasons as you mentioned, that they are not hormones. It's such a shocking revelation to them when I show them that they're actually That technically in every— and this is by our US government on the National Institutes of Health website— that they're endocrine disruptors and they don't balance hormones, they don't help, and that they're not in any way addressing the underlying issues. So the first thing is to recognize that the menstrual cycle is a vital sign of women's well-being.

Yes.

And when something is wrong with it, something is wrong with the woman. We have to just face the facts that there are issues here and not try to sweep it under the rug, which is what you know birth control pills at best would be doing because it's not addressing why the period is abnormal; it's simply trying to cover it up. So my analogy for that is you have a wall filled with mold and termites, and you don't really want to deal with it, so you just cover it with really pretty wallpaper. But I mean, well, you know it's obvious you're not addressing the real problem. So we have to address the underlying problems. And so with that, I explained to women that, guess what, I am your guide. I can't fix you. I can help you to access the tools so that your body can heal itself. And that means you have to do all the hard work. So I always try to gauge level of motivation because that is a big, big hurdle for a lot of people.

Yeah, definitely.

How much do you really want to be well? And how much work are you going to do? Because it's going to be a lot of work. You know, once you really understand the full complexity of the female body, and then you know that there is no quick fix. And we live in a world where everyone is looking for the magic pill, the quick fix. And when I explain that this is a journey that will probably take a year before, you know, you're even close to where you want to be, because this is a lifetime in the making. This is pre— Being born, you know. So we're working on so many levels here. That doesn't mean we won't see a lot of progress over the course of, say, a year, but, you know, it's a process, you know, and there is no magic pill to address all the different issues that a woman's body can be facing and dealing with in order to try to help her to achieve what she really wants, which is to be healthy and happy and vibrant and be able to do everything she wants to do with With clarity of mind, with good mood, with energy. And that is not ever going to be found in a birth control pill, in an IUD, or, you know, any— and even, you know, with hysterectomies. And of course, sometimes these things are necessary. That's why I try to explain, if someone comes into my office and they have fibroids the size of 2 bowling balls, you know, I can't magically make them disappear.

Exactly.

That's why we have to be We have to be on things early. We have to be proactive. Like when someone comes in and they have horrible bone density because they have had anorexia, they've been on birth control pills most of their lives, and then they're 15 years out into the menopause and they have had no hormone therapy and a terrible diet, I can't magically make their bones wonderful. But no matter what someone is at in terms of their level, their stage, their health, degree in terms of illness or wellness. We can always do a great deal to make things better, but the earlier we get on it, the better. So everybody, you got to get started tomorrow or today, you know, depending on the time of day you're watching this, so that you can make your everyday, every future day in your life to be a better one.

Yeah, that's totally the truth. And my guess is you see women in the same state that I do. They have been doctor shopping. They have been through the gamut of surgery And medications, and they are at the point where they almost are hopeless, you know?

Mm-hmm.

I have a lot of Kleenex in my office because they finally break down and realize that they cannot get better and they've gone every other place. And so they say, you're my last hope. And that sometimes feels overwhelming to me, but it's also an honor. And I'm excited because now I have tools in my toolbox that I can actually help heal them or help guide them to heal. So I just want you to tell these women they can have hope. There are options out there to heal. You don't have to just not feel bad.

Oh, you know, if there's one thing I insist upon, and that's like my mission, is that every woman who walks out of my exam room walks out with infinite hope and knows 100% that that they can do so much better. You know, I'm always realistic. You know, I never let best be the enemy of better. You know, so we don't have to be perfectionists in everything. You know, sometimes better is the best goal. And so to feel better each day is a wonderful thing. So many women live with so much pain, physical and emotional pain. Like you said, Kleenex boxes are everywhere.

Yeah.

Because no one has listened. I mean, sometimes I have to spend the whole first— the whole visit, the first visit, just listening and hearing the woman's story. And they often end with saying, you're the first person who ever asked me anything about myself.

Mm-hmm.

You know, whoever actually cared, whoever listened to hear my story. And that in itself, you know, what we call the doctor-patient relationship, the healing relationship, which I think is so critical and cannot be achieved with programs that are group, you know, group programs. I'm not against group things, but, you know, there's something about the one-on-one which I hope will always stay and not be eliminated with, you know, telemedicine where you don't even know who's on the other end of the call, you know, like, which is happening now rampantly, right?

Yeah.

And, um, and other kinds of things that take away that personal connection, because just having that personal connection with someone who you know cares about you and is going to be there for you can tremendously alter the healing course because we know that the emotions can affect everything— the immune system, the neurological system, everything. So we know that pessimism is always going to take you down a bad path and optimism can, can heal. Now, you know, I think almost every miracle healing is because that person Suddenly had hope.

Right.

And things in their bodies changed. It changed the way their neurological synapses worked and the production of neurotransmitters. It altered the permeability of their gut. You know, it changed how their immune cells reacted to inflammatory stimuli. You know, it's amazing what emotions can do. That's why I'm very big on mind-body medicine, because it's not woo-woo. It's real. It's just so real. to incorporate, you know, all kinds of modalities, and you have to find the one that the person will adapt. There's so many different ways to help people to feel calmer, less stressed, and feel more hopeful about each upcoming day.

Right, right. No, I totally believe we have to treat the mind, body, spirit. I mean, you just— you can't get well without addressing all 3 areas. You probably don't realize it, but I've been stalking you for years. I've been studying you and watching everything you're doing. You're You know, an amazing gynecologist. And so you've kind of been my secret mentor. You didn't even realize it, but, um, I was super—

I hope there are more of you out there because then we can create, you know, like a mass effect, right? I know, I know. We need to band together. There's so few integrative functional gynecologists out there. There's like this many. Yeah, exactly.

I know.

I think you said we're like unicorns. So when you came out with your book, the PCOS SOS book, that was just beautiful. I just think women need to know that there are options out there and they have so much control over getting well. For my listeners, polycystic ovarian syndrome is a complex syndrome of symptoms, and so a lot of physicians don't understand it themselves.

Yeah.

And so they— it goes undiagnosed, and I just think so important that you brought this to light. What prompted you to write this book?

Well, it was somewhat in the works for a very long time. I had almost completed the first version when both of my parents became very ill, and then I spent the next 2 years actually caring for them at the end of their lives and running to nursing homes and hospitals, and my poor book just didn't get any of it— any attention. And then later After that whole phase of my life was over, I just felt like I was into a new phase and that book just languished. And then I just started looking at my patient population.

Mm-hmm.

It was so overwhelmingly growing with women with PCOS. I said to myself, okay, you know what? We're going to sweep away all the old dust and everything else that went with it because I had all the emotional overlay of I was almost finished when my parents became ill. And I really started over, only this time, I brought in a different generation. I brought in my daughter, and she became my teammate. And together, she looked at, like what you did, she looked at all of my webinars and blogs that I'd written and the different podcasts. So, she went and saw lectures that had been recorded. And so, she went through all that, and then we had meetings together, and then using my voice, together. Like, she would write it on Google, and then, you know, and then I would be able to go in and I would edit it because we would, you know, do the whole thing over through the Google. And it was just great. We wrote it together. It took about a year. And then we decided to create the next wave, which would be the Fast Track books, where those would be 12-week, week-by-week programs exactly telling you what to do so that you would get what you want out of life. So the first book, PCOS SOS, is the foundation book. It has hundreds of references. It explains everything about PCOS, and it's a 7-step program. So it does tell you very much what to do so that you can take control of your body and your health and your future without pharmaceuticals. And I, I do prescribe pharmaceuticals in certain cases, but Every woman can access her inner health by— anyone, any woman and every woman with PCOS should be able to be helped by my foundation book, PCOS SOS. And then the newest one, which just came out at the beginning of this year, 2020, is the fast track. So it's PCOS SOS Fertility Fast Track, and it's a 12-week, as I said, program telling you week by week exactly what to do, what to buy, what to eat, so that you can in just 12 weeks Seriously improve your chances of becoming pregnant, having an uncomplicated pregnancy, which is so prevalent among women with PCOS.

Right.

And a healthy, uncomplicated delivery, healthy baby. So that's what it's designed to do. And the vast majority of women will, even if they can't get pregnant right away, their chances of becoming pregnant, even if— because I have to— I'm always honest about everything. There are some women that Maybe need to lose well over 100 pounds. They're not going to lose 100 pounds in 12 weeks. That would be terrible. That would be way too fast.

Right, right.

But it gets them— so a high percentage will get pregnant shortly thereafter and some may have to repeat the program for another 12 weeks. Or if they do go into something like assisted advanced reproductive technology like IVF, their chances of success will be much greater because women with PCOS have the highest failure rates with IVF.

Yeah.

And they have incredibly high rates of miscarriage and also complications during their pregnancies. And then their babies often will have medical problems. So we want to do everything to optimize every step of the way. And that's really what the Fast Track is designed to do. And the main— I'll call it like the foundation book— is really, I think, should be mandatory for every woman with PCOS to get her started on her health journey, even if she decides to use pharmaceuticals. And it's just like when they do studies with diabetics, and there's a lot of insulin resistance in women with PCOS. They did studies comparing lifestyle, diet and exercise changes, with metformin, the sort of, we'll say, foundation drug for diabetes and prediabetes. And which one? Exercise and nutrition changes. Lifestyle beat metformin. And they did a study using berberine, one of the supplements that I will often use for a while, and that's an extract, an alkaloid extract from certain plants like Oregon grape root. And they compared it in women with PCOS who were undergoing IVF to women who were on metformin, and the berberine group beat the metformin group out. So there's so many studies that have shown that natural products plus lifestyle can beat pharmaceuticals. So it's, it's every— everything that I use and everything I recommend is very evidence-based. So I'm very scientifically oriented. Yeah, that's what I love about you. That's why we have hundreds of references. And, you know, just talking about it's not just what you eat. Of course, that's critically important. It's also when you eat. It's also when you don't eat, you know. So these are like utilizing the newest information we have about circadian rhythm. About gut microbiome and the newest information about how the immune system works. All of these things intertwine in women with PCOS. So I call PCOS the poster child for showing the intimate and critically important interconnection between reproductive functions and metabolic functions and how the two are totally intertwined and they're the same in one body. So reproductive health and metabolic health are really one and the same. And gynecologists don't get that. Endocrinologists don't get that. It's like so blatantly easy to grasp. Of course, nature would not evolve women so that they can be incredibly fertile while they're incredibly unhealthy. Right?

Right.

That would obviously not make sense. That's why fertility is a sign of health. And the ancient populations of this earth understood that. They had fertility gods. They understood fertility was life. Fertility meant health. And now, you know, we spend a lot of time and money trying to get rid of fertility without understanding the potential implications down the road as well, like with chemical contraceptives that are being, you know, paraded around as hormones when of course they are not. They're like the anti-hormone.

Right.

And, you know, so it's so important to understand the link. And the biggest link, which is my favorite hormone that I always talk about, is estrogen, which is the link between reproductive functions and metabolic functions. And the reality is that when you look at everything that goes on in women with PCOS and everything that goes on in metabolic terms with women in menopause, they look the same. If you wrote a list of all the metabolic dysfunctions of women with PCOS and of women in menopause, they're the same because they're both about dysfunction or insufficiency, deficiency Of estrogen in the body. And the biggest difference, of course, is why they have estrogen deficiencies. The reasons are totally different, but the manifestations are very much similar. And then, of course, women with PCOS have functioning ovaries that are malfunctioning in that they're producing far too much testosterone, which is not the same because the mechanisms are different in menopause, but they both— show the link between estrogen and metabolic health. And, and that's why once you grasp that these processes are all interwoven and that estrogen is the glue that puts them all together, then understanding what's happening becomes much easier. And then understanding why certain things that are conventionally utilized are really not a good solution. Like even metformin, which is used now in women who are pregnant with PCOS, And of course, gestational diabetics as well. And it's an endocrine disruptor. And they have published articles showing that the children born of the women who are using metformin throughout the pregnancy already by age 4 show metabolic dysfunction. They have more body fat relative to other children who had similar moms in terms of their medical history. And they have more belly fat. They have more visceral fat. They're metabolically unhealthy.

Mm-hmm.

And that's because metformin disrupts the metabolism. Metformin, and this is in the environmental science literature galore, metformin is itself an endocrine disruptor. So we're actually treating pregnant women with an endocrine disruptor. And in terms of benefits, the studies that have been published show it has actually no benefit on reducing gestational diabetes, preeclampsia, all the things that we thought we would be reducing.

Mm-hmm.

They actually do not reduce. benefit came back a very slight difference in preterm deliveries, but it was so nominal. It was hard to even believe that. But that would be one possible benefit of like a week difference in when the babies would be born. It really did not justify using an endocrine disruptor. That's for sure.

Yeah, exactly. I couldn't agree with you more. So we work so hard to get women with PCOS balanced and be able to ovulate again and get pregnant. But can you explain to my listeners why diet is so important to get PCOS under control? Can you talk about the insulin resistance that goes along with that?

Well, it's important on so many levels. So first, I'll start by saying that back in 2012, my dear friend, Professor Kelton Tremellen, in is an endocrine reproductive specialist in Adelaide, and that's in the southern part of Australia. He had published a hypothesis that he called the Dogma Hypothesis, which was a hypothesis paper that women with PCOS have dysbiotic gut microbiomes. In other words, the microbes of the gut of the women with PCOS are abnormal and they're malfunctioning and it's causing leaky gut, and then inflammation is increased through this All the endotoxins, the lipopolysaccharides, what we call endotoxins leaking out of the gut into the area surrounding the gut with the immune cells, creating an explosion of inflammatory cytokines which circulate through the body and create systemic overall body inflammation.

Right.

Well, that has now been proven. His hypothesis was spot on and there have been several papers now published. The first one came out of China where they had a lot of support. To actually, because this is an international epidemic now, PCOS. There's a lot happening in India, in all areas of Asia and China. And so it's shown that 100%, there is a problem with— I mean, I guess you can never say 100%, but they showed in all the different published papers, there is a problem with the gut microbiome, that it's dysbiotic, creating leaky gut and this endotoxins.

Right.

Circulating out into the body. So how do we help this problem? Well, we have to try to nurture those little critters, those little trillions of microbes that live in our gut. So the food that they love is fiber. So there's been this epidemic of people talking against fiber because they say, don't eat starch, don't eat starchy vegetables. Well, that's what feeds our microbes.

Mm-hmm.

It's very different if you say, Don't eat a bowl of candy versus you should eat a bowl of roasted root vegetables.

Right.

But you know how these things are getting confused in people's minds and they start thinking carrots are dangerous?

Oh, I had a woman bring me a report that said— the title was Why Fiber Causes Death or something. I was like, oh no, we need to have a conversation. I mean, it's crazy. No.

The reason that we didn't have issues— I mean, there are so many, but one of the reasons that we didn't have issues with polycystic ovary syndrome in ancient times was that women ate so much fiber.

Yes.

I mean, in primitive-type communities, when they've looked around Earth where we had societies where they hadn't yet been westernized and so on, they ate so much fiber, like 100, 150 grams. And now many Americans eat like that.

Yeah.

They're basically starving their little microbes. And if the microbes starve, they can't make what are called their metabolic products, short-chain fatty acids, which do all kinds of things. They signal to the liver and they work. They go out to the vagus nerve to keep you calm. They actually can be food for the lining cells, the enterocytes of the gut, and also for the brain because they are Fatty acids. That's what they are. So there's acetic, propionate, and butyrate. So we have these fatty acids that have all these multitudes of functions, but you can only make them if you eat fiber. In addition, when you have this terrible gut inflammation, you know, it's that this low-grade chronic inflammation and you don't have the good microbes, you don't have the short-chain fatty acids, you get— Gut leaky gut. Fatty liver. And now this is also at epidemic proportions. Women with PCOS have very high rates of fatty liver. When you have a fatty liver, you have an out-of-control inflamed liver and it goes into a state that we call uncontrolled gluconeogenesis. So it just starts pouring out glucose, just making sugar unrelated to what the body needs. Also triglycerides, it pours out the fats. Mm-hmm. A big part of why women with PCOS have this insulin resistance is because they have the perfect storm. They have all this inflammation because they're— when you have all the gut dysbiosis and you have the toxins coming out, that's creating total body inflammation. Inflammation causes insulin resistance. And in addition, this was shown by researcher Frank Gonzalez out of the University of Indiana, and this was back at the— just before the year 2000, I think it was like 1998, that the immune cells of women with PCOS have a lower threshold to producing inflammatory cytokines, these inflammatory particles that circulate. And that's also— we didn't know then, but now we know it's because estrogen modulates all the inflammation and all the immune cells, and women with PCOS don't make enough estrogen. So you have all this endotoxin, you have immune cells that produce cytotoxic kinds of inflammatory products at a much lower threshold, and you have all this inflammation that leads then to fatty liver. The liver is spewing out all this glucose and you have insulin resistance. And of course, this is leading— that even leads down the worst path because when you have high levels of insulin, because that's what— when you have high levels of sugar, you then have proportionately high levels of insulin, and then insulin leads to production of IGF-1, another hormone, insulin-like growth factor 1, which in turn triggers more testosterone to be made.

Right.

It's like a spiral without control, like snowball going down, no control, no brakes, and it just keeps getting worse and worse. When you have high levels of insulin, You make fat. So you have all that sugar and insulin, which is necessary for life, but when you have too much, like anything, too much of a good thing, you can't live without it, but too much, you just keep turning all that sugar into fat. And it turns into the worst kind of fat, the visceral fat, the inflammatory fat around the belly, because they also have high amounts of cortisol because they have so much stress going on in their bodies. So that's the stress response.

Yeah.

So you end up with all this visceral fat and they can't lose weight because you have all this insulin.

Mm-hmm.

So that's where you have to eat not just the right foods, but the right timing. So it turns out that we are all most receptive to food or insulin sensitive in the early part of the day. And so many people are going out and about and spreading this wrong information that people should be fasting. Until the afternoon. And that's actually, especially for women with PCOS, about the worst thing you could do because then whatever they're eating in the afternoon and into the evening, they're the most insulin resistant. So their body is going to maintain higher sugar levels in their bloodstream and have to produce more insulin to try to transport that sugar across the cell membrane and into the cells. So there was a great study out of Israel. It was a small but amazing study. On women with PCOS. They had them eat about 2/3 of all their food, all their calories for the day, for breakfast. And then they had a medium lunch that was about 1/3 of the food for the day, and then just a few bites for dinner, and it was early. In 1 month, their testosterone and insulin levels fell by about half.

Wow.

And their 17-hydroxyprogesterone, which is a precursor to Cortisol, which women with PCOS, as I mentioned, they're in a state of stress and they have high cortisol, which then promotes even more insulin resistance. That's the whole perfect storm. That went down almost 40%. So how amazing is that? There's no pharmaceutical that does anything like that.

Right, right.

So for women who are highly motivated, if they can eat most of their food for breakfast for the day and then have either A medium lunch, light dinner. I have to be practical. Most people are not going to forever give up dinner, but if they have a big breakfast, a tiny lunch, and then a medium early dinner, that is very good. I have patients who have lost 60, 70 pounds by having what I call the giant breakfast salad. They have a salad bowl, okay? What would serve a family of 4 or 5. But that's their breakfast. They eat the whole thing. So not only are they getting like really full because they're eating so much food, but they're getting tremendous amounts of fiber, polyphenols, those magical ingredients.

Yes, eat the rainbow.

That's right. And all that, the antioxidants to help reduce their inflammation. Remember, they're in a state we call oxidative stress. You know, they're like internal rusting. They have all this inflammation. So all of these plants, all of the colors of the rainbow, like you said, and then putting in nuts and seeds and going vegan for about 6 months. Because when you have the wrong microbiome, you don't process animal protein properly. You actually make toxins, even carcinogens.

Mm-hmm.

So that can come a little bit of animal, but later. So if we just— when people do this, and I've had patients do this, it's like their body just transforms because they're living with their natural circadian rhythm. And women with PCOS, other people can maybe get away with more. They don't. They don't have the room for any of that sort of leeway. You just don't. So you have to really understand what your body is doing. And this also will help women who are in menopause because they also have circadian rhythm dysfunction. The master clock that sits atop the optic nerve in the brain controls the timing of everything in the body. But we have a backdoor way when— because with women with PCOS, and this has been published, a small study because there's just such a shortage of research for women with PCOS. Right.

Right.

And what there is is almost all related to fertility, not about metabolic health. So that's what we're doing for everyone out there. There are nonprofit organizations, PCOS Awareness, PCOS Challenge. that are working all the time for advocacy to inform and educate our legislators and the population and doctors about PCOS so that we can get more research, more education, more help for women so that we don't just have this ridiculous, go on birth control pills, which actually are metabolic toxins.

Mm-hmm.

I mean, everyone knows that birth control pills can increase your risk of blood clots. Well, women with PCOS have increased risk for blood clots and there's published articles showing that if you take women with PCOS and then you put them on birth control So if you're on birth control pills, you're even increasing above the baseline of being on birth control pills, which is higher, even higher than that, you're risking them getting blood clots. So that is a terrible thing. And then they have to accept that those are not the solution. They lower the production of what's called nitric oxide. Nitric oxide is critical for maintaining vascular health so that you don't have leaky arteries. That's a very big problem. Or develop plaque in your arteries, and birth control pills promote that. So we all know that you would never give someone who is a heavy smoker or even a smoker at all, or someone who just had a heart attack or stroke, birth control pills. But women with PCOS have metabolic risk, so they really should be in that same category and not get them. And so we just have to educate on that. So when women are— women have PCOS because they don't have enough estrogen, and estrogen helps regulate the master clock. So they always like sort of a little bit like they're living a life of jet lag.

Right.

Okay, so they're living like in a different time zone. And we all— we know— well, in case, you know, doctors sometimes know, but not everybody knows that people who work night shifts, for example, they have circadian rhythm dysfunction. I had that. You had that. Anyone who does all that obstetrics has it. You know, it's a problem. But people who fly across time zones all the time and they're going in and out of different time zones and so forth, they have higher rates of Anxiety, depression, diabetes, cancer, especially breast cancer. So these are serious risk factors and they are inherent in women with PCOS because women with PCOS basically live a life of jet lag. So one of the things that we can do the backdoor way is through like the gut microbiome. So the gut microbiome, they're living creatures and every living creature works with the circadian rhythm, the beautiful 24-hour rotation of Earth on its axis. Mm-hmm. So every living creature has clock genes. So by feeding your microbiome at the right time and not feeding them at the wrong time, you're actually going to help heal your gut.

Yeah.

It's like so amazing. So like if you're a nighttime eater, you eat in the middle of the night, which a lot of women do when they have circadian dysfunction, their appetite is so dysregulated. They get the night munchies and they often feel more awake at night. If any of you feel that way, I can tell you have circadian rhythm dysfunction and we need to work on it right away. And it takes sometimes weeks to resolve it. That's where you have to use willpower for just a while. But if you start by having a really big breakfast and then hydrating a lot with herbal teas, you'll get through this much faster into getting your clock back in order. So women with PCOS, by, I say, eating to the beat, by not snacking, by having a big breakfast, that actually gets It gets the clocks of your microbial population, your microbes' clocks, back in sync with your liver clocks, with all your other organ clocks. And by eating to the beat, you can help to heal your gut. So you've got to feed those little microbes. You've got to get them regimented. You get them back on the clock at the right time. And then you have to sleep because it's found that melatonin, which only made when you're sleeping. Okay? Very little bits come out in the evening before you sleep, but the bulk of it is made while you're sleeping and a lot is made in the gut. This also helps to get your microbial population and your gut healthy. We know that people who don't sleep well have very high rates of acid reflux.

Yes.

They have dysfunction of what's called the enteric nervous system, the peristalsis. That doesn't work properly. In people who don't get adequate sleep and they don't have that wonderful melatonin, which has so many functions. And one of them is to sort of get the microbes sort of in proper alignment. And there are certain microbes that actually swarm like insects in the presence of the melatonin, and they create signals that help to signal other microbes and also signals that go to the liver as well, because there's a really close connection there between The gut and the liver. So just getting sleep. So we talk a lot in my book about sleep hygiene and how to sleep and how to work with circadian rhythm dysfunction, sometimes using melatonin as a supplement, seeing the sunset, getting a light box for getting bright light in the morning and at midday. So, and none of this is going to be helped by a pill. There's no magic pill for this. That's why you have to do a lot of lifestyle adjustments.

Yeah.

But the payoff is phenomenal.

Yeah, so true. Yeah, your life changes drastically once you start sleeping regularly. I learned that last year when I gave up obstetrics. You know, all of a sudden I could get healthy and I had energy to exercise and move and I could think clearly.

And that's the other thing, you know, we talk of course is exercise. And it's, you know, I'll take exercise any time of the day. But if you exercise in the morning, you're more prone to losing weight. But I'll take exercise anytime, preferably not right before you go to sleep because that does rev up your cortisol production, the exact opposite of what we want.

Mm-hmm.

So as much as we can, we try to get people to exercise, to do everything based on our innate clocks and the timing that we evolved to have. So we just have to sort of harness our own healing mechanisms by harnessing our inborn clocks and getting them all set. If you picture it like you have clocks all over your body and they're all working in different time zones, then that will make sense to you why we have to get everything into a coordinated whole and that we have all these techniques to help women with PCOS to get that back together again.

I love thinking of it that way. I think that's wonderful. You also do a lot of educating on intermittent fasting. same idea of feeding your microbiome the right food at the right time and allowing your body to be able to be a fat burner as opposed to a sugar burner. And I just think that is so important for women with PCOS and, you know, perimenopausal times. So talk about that a little bit. I think what you've been doing with that is fascinating.

Well, I was very fortunate to be working with Professor Valter Longo, who's the director of the Longevity Institute at USC. And I was involved with the early development before it was marketed of their fasting-mimicking diet. So my office was the first one in the whole world to actually be able to experiment using it with my patient population, not looking for efficacy because that was already shown, what it could do. But in terms of usability. So they modified some of the soup flavors. I got them to take out the gluten and we changed the kale crisps to kale crackers, which are really delicious. So they made some little modifications based on feedback. And I also learned how to implement it. One of the things I learned right off the bat is that you don't start people on a fasting regimen right out the gate. So what I do is a lot of people call this fasting. And technically, if you're not eating, you're fasting, but there are these terms that We can speak the same language, so I'll just define them. So time-restricted eating is when you have periods of fasting over the 24-hour day. And that's where we do, like I said, you have a big breakfast, a small or medium lunch, and then a very tiny dinner, or reverse the lunch and dinner if you have to. And you end eating early, at least 3 hours before you go to bed. And you should go to bed at 10, optimally. But stop eating by 7 at the latest and no snacking. And if you have to snack, then it should be fat because— so what would fat be like? Olives or a sliver of avocado because you want to keep your insulin down. Okay? You really want to have low protein because protein is what the nutrient sensors in the brain pick up the most is protein. So you really want to keep your body thinking you're fasting.

Mm-hmm.

And you want to not increase your sugar or insulin levels. That's where you want to have something very small. They also now make what's called a fast bar, which has almost— has very minimal impact on blood sugar and insulin levels, and it's predominantly nuts. It's another tasty thing. I often use that at lunchtime. It's not a meal replacement. I call it a fast replacement. It helps you to stay somewhat And I always like to just mention that I initially worked as a volunteer with Professor Longo, and now I'm so fortunate that I'm part of their education team. So I get to lecture with the company that was spawned from the research, which is called L-Nutra, and their product is called ProLon for promoting longevity. And so I am on their speakers bureau and use it myself all the time. And in terms of women, I think it can be incredibly helpful. I always start with time-restricted eating and what we call in my office a reset. And it's also, we call it a detox, but you're not getting all your toxins out of your body, but you are upregulating liver detoxification pathways and you're detoxing off of processed food and high fructose corn syrup.

Right.

And we take away the dairy and the gluten and all processed foods. So it's a detox in that sense. People talk about detoxing off of drugs. We detox off of the standard American diet.

Exactly.

Help to reduce inflammation. It's also an elimination diet, so we can see if you have reactions to any foods and such. After doing that, that's when I went into appropriate candidates, which is most people. There's just a few exceptions, like if you're very frail or very old or very young or very ill. types of things would not allow you to be on a fasting program. But then I introduced the fasting mimicking diet, the ProLon, and you do for 5 days. If you do the fasting mimicking diet, it's 5 days a month for 3 months in a row. And the other days you eat your healthy diet with your time-restricted eating. And the thing that makes it so helpful is that you're actually eating because it's a mimicking diet for fasting.

Okay.

I personally have never gone more than 1 day fasting, and then I always start eating. But when you use a fasting-mimicking diet, you get 3 meals a day, but it's specially formulated to fly under the radar of the nutrient sensors in your brain. So it's like mimicking a fast, but you actually get to eat. So you get the benefit of eating and the benefits of fasting. So you get about the same benefits as if you had had nothing but water for 4 days, and you get to eat for 5. So to me, that makes it— I call it practical because if you tell a lot of people they should stop eating for 4 days every month for 3 months in a row, you'll have, I can tell you, very low compliance.

Oh yeah. Yeah. People look at you like you're crazy.

I mean, there's other ways of fasting, what they call intermittent fasting. So intermittent fasting is where you don't eat for 2 days every week. So sometimes they call it the 5:2. 2 days you do not eat and 5 days you do eat. Some people have modified it so the 2 days you don't eat, you have a tiny bit of fat, just a little bit, like maybe a couple hundred calories of fat. That would not be a lot. That would be like a few olives and a sliver of avocado. So it wouldn't be much, but that would be so little that that would probably keep you somewhat in a fasting state. But there's very little data to actually prove that. So if you want to do it perfectly, you would actually have to water fast. For 2 days every week. And what has that been shown to do? Let people lose weight. Okay. So that's very good for people who need to lose weight. The problem I have with that is sustainability. How many people are going to stay with that? Not eating 2 days every week for the foreseeable future? Like going way out.

Probably one person.

That's really hard to do. But people who want to lose weight and they can do that, that's That's going to work because they tend actually not to overeat the other days. People think they'll overeat, they'll eat double, but they actually tend not to. They sort of get into a different way of thinking about food when you stop eating 2 days out of the week.

Mm-hmm.

When you do the fasting mimicking diet for 5 days, or if you really can do a 4-day water fast, which I can't, you will also lose weight, but there is also some data, more data Yes. And there's also data on fasting, not necessarily with the fasting mimicking, but other fasting data, and I would think it's going to be applicable, but looking at upregulating the detoxification pathways. For example, upregulating cytochrome P450 enzymes in the small intestine so you can actually eliminate xenoestrogens better. Time-restricted eating and more fiber has been shown to help the body eliminate endocrine disruptors, which are horrendous for everybody. And so this is really part of the strategy because they've done some studies on women with PCOS and they tend to have a higher body load of bisphenol A, BPA, which is a ubiquitous plastic type of material, but it's also in the liners of cans and it's pretty much out there. It used to be in baby bottles. It's in hard plastics. So it's really— everyone has it in their bodies. It's a question of how much.

Yeah.

And women with PCOS may be less— the ones with the most severe manifestations may be genetically not as good at detoxifying and eliminating these. And I've looked at— and some of— most of my worst-case patients with PCOS, the most severe cases, have MTHFR double T. So they're like— they don't methylate, which is Which is a very important process for a lot of things, including eliminating a lot of toxins from the body. So there— and so people who have that need to take extra B vitamins that are pre-methylated. And guess what? Eat more vegetables.

Right.

So that's where that giant breakfast salad comes in handy in so many ways. So now there is such a thing as prolonged fasting. So that's where you're fasting more than a week or so. And I actually almost never advocate for that. Because the body is a different creature. When you do like the fasting mimicking diet and you fast water, that's 5 days, or you fast with water for 4, you actually upregulate certain processes in the body like what's called autophagy.

Mm-hmm.

And that happens only when you've been fasting for about 3 days. So you won't get that stimulated with the 5:2 where you just fast for 2 separate days of the week. And what autophagy is, is where you The body says, oh, there's no food, so we're going to have to be recycling, right? So we're going to be very thrifty. So they take the good cells and they take all the internal organelles, break them down into their component parts like amino acids, fatty acids, and then reconstruct new organelles. So it's like a total rehab of your cells. They can even do that with mitochondria. That's called mitophagy.

Mm-hmm.

So you're basically rejuvenating all your cells from the inside. And what also happens is Because when you don't have food coming in for a few days, the body says, uh-oh, no food. We better get rid of the crappy cells. So the old senescent, maybe cells that are turning bad, they actually kill themselves. They call that programmed cell suicide.

Right.

Okay? And they just kill themselves. So they're dead. And that's good because we don't want them anyway. So many organs in the body will actually shrink and then they regrow. And that's because And they've shown this in animals that stem cells can be triggered. Okay. So hopefully we'll get more human data, but there's something that's happening because they've shown with imaging studies in humans that these cells are disappearing. So they're obviously killing themselves. And then the organs are getting back to normal size. And that means that stem cells are growing new cells, new healthy cells. So you're not only rejuvenating the internal components of cells, So internal rejuvenation of cells, you're also rejuvenating organs. Now, in mice, that led to increased longevity, and there's no human data on that. But what we're looking for is not increased longevity. We're looking for healthier, higher quality lives.

Yeah.

And so, and I have seen, you know, so many, so many personal stories showing How doing these fasting routines have changed lives, really changed lives. And I never do fasting when someone is actively trying to get pregnant. That's why, like in my Fast Track, Fertility Fast Track, I say, give me 3 months. Okay? Do not get pregnant during those 3 months because we're going to increase your fertility by doing all— triggering all these processes in your body for self-healing, rejuvenation, That's the other thing that they showed with the fasting-mimicking diet is that you preferentially burn up the bad visceral inflammatory fat while you conserve lean body mass.

Oh, that's really good.

And when people go on crazy crash diets, they usually lose a lot of their muscle, their lean body mass. And muscle is so critical for a million things, but one of the things is that it actually is the biggest uptake for glucose. If you don't have enough muscle, you're going to get more insulin resistant and you're going to have all this sugar circulating and have higher insulin because you don't have the tissues to use it.

Right.

Use it or store it as fat. Which one do you want? I think we want to use it. We do not want to burn up our muscle by doing these prolonged fasts. There are people out there recommending really long fasting. People will lose weight, but they're going to lose the wrong kind of body tissue. It's not just losing weight. It's not just what you eat, it's also when you eat. It's not just losing weight, it's what exactly are you losing. We want to make sure we're losing the right thing, which is the visceral fat. And that has been shown with fasting mimicking diets. So I am obviously a big fan. I've done it myself. I'm losing track. I think it's like 17 times now.

That's wonderful.

Yeah.

And not only do you lose weight, but your hormones balance out because you're not doing that sugar yo-yo situation anymore, right?

Well, once, once your body is healthier, fertility will return. That's, that's why menstrual cycles and fertility are a vital sign of female health. That's why when a woman is infertile, not because she had her tubes tied, you know, for natural, right, not good reasons, That is such a red flag. This woman is unhealthy. And we have to get women healthy. We can't just ship them off to an IVF center where the body is tricked into getting pregnant, an unhealthy body that is not designed at that moment to support a pregnancy properly. We have to get women pregnant after they're optimally healthy, or at least better, even if we can't be best. Because we now know that women who are unhealthy during the time that they're actually pregnant, They alter the way the baby's developing, but even the genes are expressed differently. We call it epigenetic modification.

Yes.

And those children are more prone to having a lot of problems. They have more risk for metabolic dysfunction, childhood obesity and insulin resistance, attention deficit disorder. Even there've been some papers suggesting women with PCOS who are not healthy and get pregnant have higher rates of autism. And we know that that's epidemic right now.

Right.

Just not just try to trick the body into being pregnant. I understand people really want that baby, but you have to step back. Even a little bit older women, just for 3 months, just 3 months, and it can change everything so that they will have a healthier baby, that they'll be healthier. So we have to really be aware. I also want women to be off of chemical contraceptives, birth control pills, IUDs, even—

Mm-hmm.

Any kind of IUD, copper or the one that has the progestin, those types of things, implantables. Try to be off. I mean, I wish it could be a year.

Right.

But as long as possible to help rebuild the vaginal microbiome, the gut microbiome, nutrient status. A lot of these deplete the body of nutrients. They change microbiomes everywhere. They alter circadian rhythm, sleep patterns. That's not conducive to being really healthy. And then we wonder why so many women are having complications during pregnancy, abnormal labors, high rates of C-section. I mean, these are not happening in a vacuum. We're letting all these unhealthy women— they're not recognized as unhealthy because no one is thinking, what's your vaginal microbiome? What's your gut microbiome? What's your circadian rhythm been like? They're not asking the right questions. So of course they don't even realize That these women have issues before they're getting pregnant. So there's a lot of work for us to do.

Yes, there is. So we need to keep educating women. What you're doing is just so important, and I'm glad that you're willing to share all of this knowledge and wisdom. It's so important. So keep doing what you're doing. It's amazing.

You too.

Thank you. Yes, you're my idol, so hopefully I'll be like you someday. So where can we find you and follow you, Dr. Gersh?

Well, I have my own brick-and-mortar practice in Irvine, California, so that's in Orange County, Southern California. And I do see people from all over the country, the world. I also have an Instagram that's getting pretty busy. I'm posting very, very regularly now, and that is Dr.— so it's Dr. And Felice Gersh. So I'd love for everyone to follow me on Instagram. And if you go to my website, and that is Integrative— so name of my practice is Integrative Medical Group of Irvine, and the website is integrativemgi.com. I am very soon, it's almost done, I'm going to have a really nice ebook that everyone can have for free.

Oh, wonderful.

And it's going to be all about nutrition. So that should be coming out. Well, this— I don't know when people will see this, but we'll say for sure by the end of February 2020, probably sooner. So be sure that you go to my website and sign up, and I will give you my free brand-new, just hot off the press ebook.

Oh, wonderful. Yeah, I'll put a link for that in the show notes. That is so gracious of you. Thank you so much. It's been just It was just an honor talking to you and I really appreciate you sharing all your wisdom. So thank you, Dr. Gersh. Have an awesome day.

My pleasure. Hope to see you soon.

So I hope you enjoyed that conversation. Dr. Gersh is a wealth of knowledge. That was really awesome. I do want to mention that I'll do a podcast devoted to intermittent fasting because it's such an important topic. to understand, and it really does help us women balance our hormones, keep that belly fat off, and stay healthy. So be looking for that in the future. As for now, I hope you'll hit the subscribe button, leave me a 5-star review so that we can get the word out and share this with other women. So I really appreciate all your support.

You know, I do this for no money.

It takes quite a bit of time, but I just feel like it has to be done. This information needs to get out to women, and we need to support each other and lift each other up. So thanks for helping me in this important work, and go out and have an amazing day. I'll see you next time.