Hormones, Weight Gain, and Infertility
Dr. Laura Lefkowitz received her M.D. with honors in OBGYN, Psychiatry, Internal Medicine, and Radiology, before switching gears and transitioning into nutritional science. “The long hours of medical school and residency, limited time for exercise, and hospital food led me to gain 30 pounds in my 20’s,” she explains. “One day when my pants split open while examining a patient I realized I was an unhealthy doctor—doctors are supposed to be role models for our patients and I was ashamed.” Lefkowitz opened her own practice in downtown Manhattan in 2007, where she developed individualized nutritional therapy protocols for everyone from new moms, to supermodels, to those on the brink of devastating health effects from poor eating habits. “I believed it was my calling to prevent and reverse disease progression by teaching patients how to eat properly in conjunction with lifestyle modifications such as exercise and sleep hygiene,” she explains. In the process, she’s helped many people who simply can’t lose weight through traditional means—and has come up with highly specific eating plans for treating little-known conditions like Polycystic Ovarian Syndrome (PCOS). We heard about her results, and had to learn more. Now living in Florida, Lefkowitz treats patients via Skype.
What do you help people with the most?
I like to call myself the “nutrition chameleon” because I work in a lot of different areas of adult, prenatal, and infant nutrition, but I have a niche in treating women with Polycystic Ovarian Syndrome (PCOS), a hormonal imbalance.
As we age, it seems like our thyroids and hormone levels can cause pretty dramatic shifts in weight—is that something that you see and treat a lot?
Yes. Hormones don’t work individually; they work as a complicated interwoven system. When one hormone changes, it affects the production of other hormones. Hormones are chemical messengers produced in one organ that travel through the bloodstream and then are used in another organ or system. As we age, changes naturally occur in the way the body systems are controlled, i.e. transition to puberty, pregnancy, postpartum, menopause, etc. Organs can produce fewer hormones over time or become less sensitive to their controlling hormones. With age, hormones may also be broken down more slowly.
Most people assume that weight gain is caused by low thyroid slowing down their metabolism, but I find this is usually not the case, unless there is a specific disease of the thyroid (i.e. Grave’s disease, Hashimotos Thyroiditis, cancer, etc.). What I see more commonly is that as we age and go through puberty, pregnancy, and menopause, the natural changes in our sex hormones (estrogen, progesterone, and testosterone) affect other hormones like insulin—in turn, that disrupts the way our body stores and utilizes calories, which causes weight gain. The more weight we gain, the worse the system functions, causing more weight gain. It’s a vicious cycle.
How did you become known for helping women with Polycystic Ovarian Syndrome?
After I left my Radiation Oncology residency, I was 30 pounds overweight, had horrible migraines, cystic acne, skin tags, constant hunger, frequent episodes of hypoglycemia (low bood sugar), high cholesterol, and anxiety. But my menstruation was pretty regular, so none of my doctors ever made anything of how poorly I felt. They just gave me migraine meds, acne meds, etc. They treated the individual symptoms.
I became suspicious that something was subtly wrong and suspected PCOS. I researched PCOS in greater depth than I studied in medical school and learned that if I did have this syndrome, by controlling my blood sugars and losing weight, I could reverse many of my symptoms. Through extensive trial and error (I have tried every diet under the sun), I designed a nutrition and exercise plan for myself and lost 30 pounds. The weight loss suppressed my PCOS and I felt like a new person. At this same time I was taking nutrition courses, and so I started my own practice. I had great success with patients with hormonal imbalances and PCOS who failed with other nutritionists and nutrition plans, and my colleagues kept referring patients to my practice.
What exactly is Polycystic Ovarian Syndrome? What are the symptoms? How do you get the diagnosis?
Polycystic Ovarian Syndrome, (formerly called Stein-Leventhal Syndrome) and commonly referred to as PCOS, is a medical condition in which a woman has an imbalance of her female sex hormones that can cause abnormalities in menstruation, infertility, difficulty losing weight, and distressing clinical symptoms. The cause is still not known, but genetics may be a factor, as it tends to run in families. PCOS is one of the leading causes of infertility and patients are at a high-risk for Type 2 Diabetes and cardiovascular disease. A diagnosis of PCOS is made when a woman manifests clinical symptoms in conjunction with laboratory tests and a pelvic ultrasound.
The hormonal imbalance of PCOS can cause the following symptoms:
- Irregular menstruation (Oligomenorrhea)
- Absence of menstruation (Amenorrhea)
- First trimester miscarriages
- Excess weight and inability to lose weight
- Insulin resistance or excess insulin (hyperinsulinemia)
- Sugar cravings
- Excessive hair growth on face and body (Hirsutism)
- Scalp hair thinning (Male pattern alopecia)
- Darkening of Skin Areas (Acanthosis Nigricans)
- Skin tags
- Gray-white breast discharge
- Sleep apnea
- Pelvic pain
- Psychiatric disturbance (depression, anxiety, sleep disorders, etc.)
How pronounced is the incidence?
It’s estimated that 4-12% of women who are childbearing age may suffer from PCOS. Because the symptoms of PCOS seem unrelated and there is no specific laboratory test for it, this syndrome is confusing, often overlooked, and misdiagnosed by the medical community. Currently we go to a medical specialist for a specific problem, and sometimes the physician or practitioner just focuses on their area of expertise and doesn’t connect the dots. For example, my dermatologist never referred me to an endocrinologist as a cause of my cystic acne, they just kept giving me oral antibiotics and topical treatment, when really there was an underlying hormonal cause. Another example is someone who continually fails to lose weight despite dieting and exercise and the internist or OBGYN just assumes the patient wasn’t compliant with the diet or not exercising enough, when really the diet may not be working because of hormone imbalances. I think the wide range of 4-12% is because there isn’t enough awareness and education about this syndrome, and the medical community is failing to diagnose the subtle cases.
It seems like one of those syndromes that isn’t that well understood. Why is that? And what is the treatment? You mention that these women often diet and exercise to no avail: So what’s the workaround?
As with all diseases, the more we study them, the more we learn about them. This syndrome was first described in 1935 and the diagnostic criteria kept changing. Currently some experts in the field believe the name PCOS is a misnomer and have even recommended changing the name again because you can have Polycycstic Ovarian Syndrome without cysts on your ovaries, just insulin resistance or irregular menstruation with clinical symptoms.
While the cause of the syndrome remains unknown, evidence suggests that the syndrome is complex, involving multiple physiological systems. Because it’s been 80 years and we still don’t have a clear-cut cause and treatment for this disease, I believe it is under diagnosed. It’s a scary frontier for clinicians who don’t know exactly how to prescribe the appropriate medications and what diet and exercise advice to give.
Treatment is based on what symptoms a woman manifests, age, and plans for pregnancy. With lifestyle modifications such as proper diet, weight loss, exercise, and sometimes medications, women can get relief from this syndrome and prevent long-term health consequences. Losing weight can help get the sex hormones back in balance and quiet the syndrome, but in order to lose weight you have to get the hormone insulin under control first.
Weight loss is very difficult and frustrating for patients with PCOS. They may try diet after diet and not even lose a pound. They usually do not respond to conventional diets. An extremely low carbohydrate, high fiber diet is necessary to jump start weight loss and improve insulin resistance, sometimes in conjunction with medications. Once a patient loses about 10% of their starting weight, insulin resistance and symptoms greatly improve.
When I say low carbohydrate I mean ultra low. No sugar, fruit, fruit juices, liquid calories, grains, or starchy vegetables. The diet consists mostly of lean animal proteins, non-starchy vegetables, small amounts of healthy fats, and some high-fiber crackers, high-fiber, low-sugar cereal or chia seeds. This is totally the opposite of what I see in the medical community, fad diets and detoxes, where people are using liquid fasts and shake programs that are unsuccessful for people with hormone imbalances.
When someone with PCOS drinks a green drink, all their body sees is liquid sugar (albeit from natural sources) without fiber. This causes a rapid rise in blood sugar, followed by a rise in insulin, which then lowers blood sugar by storing calories as fat, and then their blood sugar drops again and they need to eat again to bring their blood sugar back up. A vicious, uncomfortable, and frustrating cycle. Cutting calories or extreme detoxes aren’t the answer. Controlling the hormones via eating the right foods is the answer.
The initial phase of this diet is very extreme in order to drop insulin levels and get the body in a glucagon dominant state. Insulin is a hormone that shuttles sugar in the bloodstream to the liver to be converted to fat. People with PCOS and insulin resistance store fat extremely efficiently. They store sugar so efficiently, that their blood sugars can drop very shortly after eating, making them feel hungry and hypoglycemic again shortly after they eat.
Working in opposition to insulin is a hormone called glucagon, which converts stored sugar in the liver (glycogen) and stored fat (adipose tissue) into sugar to be used in by the body for energy. In order to lose weight you need to drop insulin levels so glucagon can take over and start lipolysis (breakdown of fat). If you do not ingest any sugar, your body is forced to make sugar from your fat stores, and that is how the weight loss cycle starts.
After patients drop about 10% of their body weight, the insulin resistance improves and they can usually reintroduce controlled amounts of high-fiber carbohydrates back into their diet.
How does it impact a woman’s ability to get pregnant? Is the treatment the same whether you want to lose weight or get pregnant?
I like to describe a woman’s ovulatory cycle as a “hormonal symphony.” It is a very delicate, subtle hormonal system, even the smallest changes in hormone fluctuations and timing can throw off the entire cycle and block the release of an egg to be fertilized. In order to get pregnant without fertility problems, everything has to be timed right, as there is a very short window of opportunity to actually conceive. If you now throw in irregular periods, people don’t even know when or if they are ovulating, making conception even more improbable.
The heavier you are when you try to conceive, the worse your insulin resistance becomes, which causes changes in the sex hormones that are not conducive to ovulation, which makes conceiving naturally very, very difficult. By losing weight, you can improve insulin resistance, which then controls the sex hormones and can lead to regular ovulation and conception. Once the sex hormones are back in order, most women with PCOS can conceive, sometimes in conjunction with fertility medications to ensure the timing of ovulation.
Basically the diet and exercise recommendations for treatment is the same whether or not you want to get pregnant, just the medications may be different.
Based on your work with PCOS, are there any other basic guidelines you’d draw for women who are concerned about hormonally-induced weight gain (or weight loss)? Is there a golden diet for women that’s pro-thyroid?
Diagnosing a thyroid disorder is pretty cut and dry: You run blood tests, there’s a physical exam, maybe an ultrasound. If there is a thyroid issue, it can easily be addressed. I believe people are blaming their poor thyroid glands, when it really is other hormones like insulin, estrogen, and testosterone that are the culprits. There are diets to support your thyroid gland, but it is very different than a PCOS diet.
If you suspect you may have a hormonally induced weight gain, my best advice is get to know your own body and be your own advocate. Start tracking your menstruation, symptoms, weight, exercise, and keep food journals. Gather diet plans that you have tried to show your clinician. Make an appointment with your OBGYN, internist, or endocrinologist and bring your collected data with you and present your information. Explain that you are trying to lose weight via these methods without results. Ask to be worked up to see if you have developed insulin resistance or if there are any other hormonal imbalances (thyroid, estrogen, progesterone, testosterone, cortisol, etc.) that could be affecting your ability to lose weight. Hopefully your doctor will listen and either work you up or refer you to someone else who can.
Is there any correlation between the endocrine disruptors in personal care products and PCOS?
While we still have not identified the exact cause of PCOS, the role of environmental factors has been proposed as a cause of PCOS development, and could be a reason for it becoming more prevalent since the condition was first described. Bisphenol A (BPA) is an endocrine disrupter that is found in plastics, the lining of canned foods, and cosmetic products.
There has been experimental research in animals that demonstrated neonatal exposure to BPA leads to PCOS-like development, but there is no human data presently supporting this theory. There have also been studies that show woman with PCOS have higher blood levels of BPA.
There are a few theories supporting a link between PCOS and BPA:
1. High levels of male sex hormones (androgens) in PCOS may slow down the bodies ability to get rid of BPA, leading to higher BPA levels in woman with PCOS.
2. BPA can attach itself to Sex Hormone Binding Globulin (SHBG), a carrier for male sex hormones which leads to increased levels of free androgens in the bloodstream causing the disturbing symptoms of PCOS.
3. BPA disrupts the liver’s ability to break down testosterone, further leading to higher testosterone blood levels.
4. BPA may directly cause the already malfunctioning ovary to increase its production of androgens.
These theories linking BPA to PCOS warrant further investigation in humans. In the meantime, I encourage all my patients (with or without PCOS) to avoid exposure to BPA as much as possible. You can decrease your exposure by using glass or aluminum bottle for your beverages, glass bowls to store your food, BPA-free plastics, BPA-free canned foods, never microwaving plastic, and using phthalate-free cosmetics and personal hygiene products.