It's been a while since I spoke about what I'm doing treatment-wise. Really, it's because I haven't been focused on these treatments as a way of restoring my fertility, but rather to restore my health. My ultimate goals would be to attain for the remainder of my life: a) more energy, b) regularity (not the menstrual kind, the other kind), c) good levels of all vitamins, especially D, d) no more tail-end brown bleeding (TEBB) at the ends of my periods, and e) no more post-Peak pasty discharge. Many of these issues have been due in one part or another to my chronic stress. I am working on getting that balanced, and getting healthier. If from improved health I also experience improved fertility, well of course that would be wonderful and I'd be lying if I said that wasn't further motivation for me. However, I am following this new "treatment" regimen in a much more laid-back manner than any of the fertility treatments I've tried in the past. Somehow over the past 4.5 years, I've been blessed with something I never, ever had in my lifetime: patience!
So, here is the consult letter from Dr D (NaPro California, recommended to me by Dr B - NaPro Ireland, at this year's AAFCP meeting), which I received back in August. I figured I would share her suggestions for me with my readers, in case you feel this information could benefit you, as well.
It has been a pleasure talking with you and going over your records. I am in agreement with Dr. Check who believes that your failure to get pregnant thus far is due to PCOS, mild endometriosis, and adhesions. I think you may have been overtreated on medications that are not helpful. Although you have a few immunological labs that are slightly abnormal, it is more likely the PCOS, endometriosis, and adhesions are the source of infertility. For the adhesions, I agree with the approach of Dr. Check to normalize your hormones and have a repeat laparoscopy for adhesions if you do not conceive after a few months. Progesterone can work wonders. I would give yourself longer because if you are improving nutrition and taking supplements, it will take more like six months to a year or more to normalize insulin, cortisol and bowel function. If you have another laparoscopy it should be at a world class center for laparoscopic treatment of endometriosis such as the Nezhats in California or Atlanta, the Duke Center for endometriosis, or possibly the physicians Dr. Check recommended. Another laparotomy could cause more adhesions.
Significant factors affecting your fertility are your adrenal fatigue, low body mass index, and poor intestinal function. In improving your general health, your endometriosis will improve, and by improving your diet and nutritional status your ovarian function should improve.
I would like to focus on several areas:
You are a "thin" PCOS person. Even with a lower weight, you can still experience insensitivity to insulin and fluctuations in blood sugar. These have a direct effect on your ovarian function. Looking back, your fasting blood sugar was 94 in 2007 (before Metformin). This is suboptimal for a young woman. By stabilizing your blood sugar, your progesterone will rise. You are on Metformin now, but at some point might not really need it. At a later time it would be good to see how your ovaries function without it. The hallmark of regulating glucose and insulin is diet. We spoke briefly about a low glycemic diet. TCIE, you MUST eat breakfast every day and have protein for all three meals and adequate fiber. You need to carefully monitor carbohydrates. You need to stop sugar. High quality foods are very healing for PCOS and endometriosis. I am sending a formal referral to K.W. of the Lavalle Metabolic Institute for help with a PCOS diet, and also taking into account your food allergies, constipation, and need for more body fat. K. is a pleasure to work with. If you have cravings for sugars and carbs, these can be addressed through diet and supplements and will helpyou follow a better diet. Also daily mild exercise (walking 20 minutes for example) helps glycemic control. Suggestions for supplements will be below.
2) Adrenal Fatigue
When you have stressed out adrenals, you may experience "cortisol steal" so that your body ceases to make adequate sex steriod hormones in order to produce cortisol. You are now being given Cortef for this in maximal doses for a female. I eblieve it is important to address and correct the underlying causes of adrenal fatigue and get your adrenals working on their own. One possible cause is unstable blood sugar/insulin. As you improve blood sugar control the adrenals will work better. A really good bood about the interaction between blood sugar, insulin, and cortisol is The Schwarzhein Principle by Diana Schqarzhein. Other sources of adrenal fatigue could be intestinal inflammation due to food allergy and possibly yeast. Chronic viral infection can be an issue. I have in mind your shingles outbreak. Of course emotional stress can play a part. It is important also to get adequate sleep, at least 7-8 hours a night and even more than 8 whtn your adrenals are recovering. If you have insomnia you need to correct it. Coffee and sugar exacerbate adrenal fatigue, mild not excessive exercise will help also. Supplements are an important part of an adrenal recovery program. They include adequate pantothenic acid, Vitamin C, adrenal glandular extract, and adaptogens (botanicals) that help regulate your adrenals. When you are on an adrenal recovery program and correct the underlying causes, at some point you should be able to wean off cortisol. You should read Dr. James Wilson's book on Adrenal Fatigue.
3) Low Body Mass Index/? Low Estrogen
Although some women can conceive with a BMI of 20, others need to get their BMI in a range of 21-25. Increased body fat will improve your estrogen status. This may help correct the thin emdometrium in the luteal phase. It is not a quick fix, but after a few months if you have an improved diet and higher weight you could see this type of improvement. You should gain 10 lbs. of fat. In the interim, in some patients I have found a low dose estradiol patch will improve endometrial thickness (Vivelle .025). Sometimes I use this in the luteal phase and some time throughout the entire cycle. It would be helpful to obtain or repeat a day 2-3 FSH, and estradiols in the pre and post-Peak periods (along with progesterone)- off your drugs. You have not hadthis type of workup to check this for a few years, I think.
4) Bowel function
Constipation and bowel movements every three days have multifaceted negative effects. Your liver excretes metabolized hormones and toxins from your own body and from external sources. If you are not have one (or two or three) bowel movements daily these excretory products from the liver are not being removed, but are instead reabsorbed and recirculated. In addition, there is considerable immune lymphoid tissue in the gut. This can malfunction if there is inflammation from yeast, food allergy or other sources. Also, the intensive antibiotic therapy may have produced imbalances that are hard to correct. There is a high probability of yeast and dysbiosis. You stated that several years ago an Ayurvedic practitioner gave you some botanicals that improved liver/excretory function and made your acne go away. We would hope to accomplish the same thing. It is critically important to diagnose and treat yeast as soon as possible.
I would suspect yu have have suboptimal thyroid function. Did you say you had low basal body temperatures? Your temperatures at all times should be above 97.8 oral especially in the first three days of the cycle and if they dip below this, it might indicate suboptimal thyroid function. When you have poor adrenal function, you do not convert T4 to T3, and T3 is actually the active thryoid hormone. Your TSH, Free T4 and Reverse T3 appear normal. However, the latest Free T3 off treatment I saw was in 2007. It was 2.8 (2.3-4.2). You want your free T3 to be in the upper 1/3 - above 3.5. If you have low body temperatures, dry skin, constipation, and slow reflexes you may be clinically hypothyroid. I know you have gotten diverse opinions on this and been overtreated at one point. High thyroid does not cause birth defects. If you have a fertility problem, it is better to be a little too high thyroid than too low. You need to start correcting the adrenals before the thyroid. Once you are on adrenal supplements/meds, you can begin supplementing thyroid with a T3 containing product. Armour thyroid is an option, but since you have food allergies and possible mild immune problems sustained release T3 is better. You should get a new set of thyroid labs including TSH, Free T4 and Free T3. If your Free T3 is below 3.5 and you are clinically hypothyroid, get compounded sustained release T3. Get 7.5mcg tabs. Take one 7.5 for 2 weeks, then 2x 7.5 for 2 weeks, then 3 x 7.5. After a month on 22.5 SR T3, get a T3 level in the AM BEFORE taking the T3. Normally you should take the T3 on arising, but not the day of the test. You adjust the dose until it is in the upper thurd of the T3 range. DISREGARD IF YOU DO NOT HAVE HYPOTHYROID SYMPTOMS, YOUR BASAL BODY TEMPERATURE IS NORMAL, AND YOUR FREE T3 IS IN THE UPPER THIRD.
These are my recommendations:
A. More testig.
1. Maybe I didn't see all the tests, but some of yours are out of date. I would consider going off Metformin for 2-4 weeks or longer to get baseline glucose/insulin testing. You have never had a GTT. 25% of women who have PCOS, including thin ones, have an abnormal glucose tolerance. I would get a Hemoglobin A1C off Metformin (althought his takes a long time to reflect being off Metformin). Then do a fasting adn 2 hr 75 gram glucose tolerance and fasting and 2 hr 75 gram insulin at the same time.
2. Repeat day 2-3 FSH, pre-Peak estradiols, and post-Peak estradiol and progesterone on P+5, 7, and 9. We do not have a very good idea of what is going on with your hormones right now. It would help assess your estradiol production.
3. You need a good stool analysis to test for yeast and dysbiosis. It wouldn't hurt to check overall inflammation level, parasites and limited food allergy effect. A good one is the DiagnosTechs complete profile. It is about $200-250. I can order it for you from my office and you can mail the kit back. It includes saliva samples for antibodies.* I have reached a new low. I will be mailing my POO cross-country. Suddenly the song "I Left My Heart in San Francisco" is playing in my head, with slightly modified lyrics...
4. Consider repeat food allergy testing with Metametrix in the future.
B. Dietary consult with K.W. for PCOS, weight gain, food allergy and constipation. Please fax the latest chemistry labs, CBC, thyroid and your food allergy profile to her at: (provides #). She will send you a questionnaire and then you can make a telephone appointment. We should send her your stool analysis when you do this. Ask her what she thins about the validity of the rice sensitivity elicited by your LEAP (it might not be real).
C. Meds and Supplements:
The meds you have listed are baby aspirin, Lovenox, Metformin, Naltrexone, and Prometrium. I personally do not think there is enough evidence to keep you on Lovenox (or even baby aspirin). With your constipation issue, I would recommend to switching to progesterone vaginal capsules 600 mgs (compouded by Kubat ) P+3-P+12. The Prometrium puts too much burden on your liver, creates metabolites that recirculate and is constipating. I would not be surprised if 600 mgs progesterone vaginal capsules straighten out your bleeding. *(I would be.)
I think the Naltrexone is good. I recommend going off Metformin temporarily, and see how you do off and on it perhaps for three months at a time. You have said you are going back on Cortef and Biaxin. Why are you going back on Biaxin? I personally would not take any more antibiotics ever unless you have a very clear indication. If the Toth protocol did not clear up brown bleeding, Biaxin is not liekly to. If you go back on Cortef, I would consider lower than a total of 20mgs per day - maybe 7.5 in the AM and 5 at noon. Or consider compounded sustained release cortisol 10 mgs in the AM.
The supplements I have listed for you are Vitamin E, D 4,000, Calcium 1200, Nature's Best probiotic, fish oil, chinese herbs. An oversight of mine is that I did not recognize that you were on Chinese herbs. I am not sure they are compatible with the herbs that I am recommending for you. In addition, I worry about herbs sourced from China or India because they are often contaminated with lead, mercury, and other heavy metals. These can be extremely harmful. I willr ecommend botanicals for you but I am not sure if they are compatible with your chinese herbs. You should not continue both without more expert consultation. I am chagrined you Chinese practitioner is giving you herbs for your "cycle" but has not addressed or fixed your constipation. This to me is a red flag. I would recommend you go off these herbs while you are initiating new ones for your liver and adrenals. If you do not want to do this, get a consultation with one of the doctors at the Lavalle Metabolic Institute who is an expert in hebs. These docs also could help address other problems and be very helpful with supplements, with a greater depth of experience than myself. * (I ran out of the Chinese herbs over the summer, and haven't taken them since. I only included this part of the letter so that those of you combining acupunture/TCM with other nutritional/holistic/supplemental approaches would be aware that they may not be compatible and could actually work against you.)
1. Optivite: This is the premier PCOS vitamin. You need a high dose vitamin to include enough Bs. You cannot get enough in one vitamin, and need to take 4-6 a day. Six would be better. 4 in the AM and 2 in the PM (4:00PM or dinner). It also has 1500mgs of C which is good for adrenal fatigue and selenium for the thyroid. 180 pills, 6 per day for 30 days is $18.
2. Adrenal Supplements: You did not give me your blood pressure. There are two possible adrenal supplement programs for you:
a. If your BP is < 120/80 (Mine is) and excellent adrenal supplement is Adren-All from Orthomolecular. Take 2 in the AM and one at noon for now. It includes adrenal glandular extract, Panthothenic acid 350 mgs and a good selection of adaptogenic herbs. You can get this on the internet (amazon).
b. If your BP is >120/80 an alternate program is adrenal CORTEX 250 mg (Allergy Research Group) (not whole adrenal) 2 in the AM and one at noon; Phyto ADR (Pure encapsulations). Take 2 in the AM, one at noon or 4 PM. If you continue to have sugar cravings there are other alternatives.
3. Liver Support
You should take milk thistle 150-300mgs two times daily or LIV52 (Himalaya) two times daily for now. Milk thistle is widely available. LIV you can get on the internet.
4. For constipation you should take fiber 35-45 mgs daily. Learn the fiber content of foods. I would recommend ground flax seed, which you can add to shakes. For constipation AND adrenal fatigue, you should also add Magnesium glycinate, citrate, oxide, or other magnesium 150-200mgs 3 times daily. This will not be excessive even in addition to the Magnesium in Optivite. In addition, another 100 mgs of Vitamin C will help constipation. You could actually go up in 100 increments to higher Vitamin C until constipation disappeared.
5. You almost certainly have yeast and dysbiosis. You will need a yeast treatment program. First you should do a stool analysis. Then you should get a strong probiotic such as KlaireLabs TherBiotic Detox support with 50 billion organisms for a couple months, followed by a good but less potent maintenance probiotic.
TCIE, I wish you the best in your attempts to get pregnant. Please email me for further questions.
Our phone consult lasted almost 2 hours. She has been soooo nice and helpful, and I am so thankful that I found her! Another big plus is that my local NaPro Dr is so awesome, and has been helping me to implement all of these suggestions, as well as lining up all the testing for me. I am currently doing the pre and post-Peak OFF MEDS (off Metformin) bloodwork this cycle, and my NaPro Dr also had me do an ultrasound series, which I did on myself ;) I saw a cumulus oopherus, which is great because on other ultrasound series we haven't always seen one. (The cumulus oopherus is the cloud of cells that you can sometimes see on ultrasound in the dominant follicle. It forms around an egg, and ONLY forms around an egg - so if you see one, it is proof that there is an egg in the follicle, but if you don't see one, it may just be too small to see.)
I briefly came off Naltrexone before reading this letter in its entirety, because Naltrexone was really expensive. However, that was the cycle I had the raging week+ long PMS. So I spoke with a client of mind who actually compounded her OWN Naltrexone, and she told me how to do it. So, my kitchen has now become a compounding pharmacy, and I'm paying $10 for a YEAR'S WORTH of LDN (low dose Naltrexone!) because I get 30 tabs of 50mgs, and one 50 mg tab lasts 2 weeks! I used to pay $45 for one month!!
I am in the process of weaning off the Hydocort/Cortef, to start the Adren-All supplement Dr D recommended. I am down to 2 pills per day, and will likely start the Adren-All when the next cycle starts, so as not to throw off the labwork too much in this cycle.
I ordered the Optivite, and I'm surprised I never knew about this vitamin until now, it being the premier PCOS vitamin and all! I am taking 4 of those and 1 of my Neevo (because I do believe the L-methylfolate in Neevo is crucial for my MTHFR... I cannot process regular folic acid, high doses or otherwise, so the Neevo makes it in the already broken-down form).
I've been taking Magnesium since I spoke to Dr D back in August, as well as improving my diet with more protein and fiber. She had also suggested I stop dairy, which she didn't write in the letter. The combination of all of these things has lead to regularity, which has been AWESOME!
I still take my baby aspirin daily, but no more Lovenox for me. If I ever do get pregnant, I will really have to do some thinking about whether or not to go back on the Lovenox... it's a tough one...
I will be doing the stool analysis this cycle, and am interested in starting that detox program for yeast and dysbiosis. Maybe it will help my post-Peak pasty, too?
I've been using Agave Nectar as a sweetener in my tea and in cooking. I don't generally eat too many sweets, but I do enjoy the ocassional gluten-free/dairy-free brownie. Mmmm... brownies...
Next cycle my local NaPro Dr and I have plans to begin the high-dose compounded vaginal progesterone capsules post-Peak. I seriously doubt it will take care of the brown bleeding, but we'll see.
I have not started the milk thistle yet, I keep forgetting to buy it when I'm at the store. Does anyone else take this?
So, things are moving along in the nutrition/supplement field, but my chart has not yet shown any improvement. In fact, the past 5 or 6 cycles, I have had the WORST mucus I've ever had, throughout the whole Peak-buildup. Gummy and Gluey, every time. It is sometimes lubricative, sometimes crystal clear, sometimes stretchy (mostly tacky, though)... ALWAYS gummy/gluey. It. Sucks. In fact, the last beautiful, perfect 10KLs I've seen were the cycle of my last surgery in June, when I was in Cancun... without DH. Since then it's been MIA.
But interestingly, one of the things we look for with a NaPro follicle study ultrasound is the cervix, and the width of the cervix (if it has fluid in it, indicating it is open with cervical mucus present). And on ultrasound, during the days when I was only seeing gummy/gluey mucus, my cervix was TO DIE FOR. Seriously, if you had seen it, you would have wanted it. I have the best cervix on the block. No joke. It was WIDE open, not just in one section (which I often see when scanning other women), but ALL the way throughout the cervix, with beautiful mucus galore. Now we were taught in ultrasound school that fluid is anechoic (void of echoes) and therefore shows up black on ultrasound. We were also taught that other tissue types, like fat, skin, muscle, bone, have varying degrees of sound attenuation and therefore differing echogenicities... but one thing we never learned is how does sound behave through gummy/gluey cervical mucus?? Becuase it certainly appeared BLACK and anechoic, indicating it was fluid (liquidy mucus, you know, the GOOD kind)... so what the heck is going on? Did I have great mucus IN the cervix that just didn't want to come out, so it sent its retarded gummy/gluey cousin out onto my toilet paper??
And like Eddie Izzard, I like to end my blog posts with that kind of... Hmmph... feeling, so...