Pregnancy and PCOS Q&A With Dr. Aviva Romm

Welcome to Episode 2 of Season 8 of The PCOS Revolution Podcast:

Pregnancy and PCOS Q&A with Dr. Aviva Rom

Are you pregnant or thinking about becoming pregnant? If so, this episode is for you. Our guest today shares great tips, tricks and insights into navigating a healthy pregnancy while having PCOS.

This week on PCOS Revolution Podcast, I am having a conversation with Dr. Aviva Rom. Dr. Aviva is a midwife and herbalist. She is board certified in family medicine with obstetrics who’s been bridging traditional medicine with good science for three decades. Her focus is on total health ecology.

Dr. Aviva currently lives in western Massachusetts in the countryside. She had an early inspiration to become a physician. She went to college at age 15 to become an MD. She was then exposed to herbal medicine and became passionate. She actually found out her grandma was an herbalist. Additionally, she began to explore the role of diet and lifestyle as well as exposure on our health.

Since then Dr. Aviva went vegetarian and vegan. She noticed weight that she gained resolved without having to ‘diet’ or exercise more. Allergies and sickness also subsided. Then she was exposed to midwifery. Functional medicine was not a popular thing when she discovered it. She had to navigate very few resources for these in order to study these topics. 

Dr. Aviva recommends probiotics during pregnancy with PCOS. She also suggestions to take two tablespoons of flaxseed to help get rid of extra estrogen. It can also help with pregnancy constipation. During the episode we dive deeper into various things you can do while pregnant. We’ll chat about blood sugar balance in pregnancy as well.

READ the entire transcript here:

Read Full Transcript

Farrar Duro

Welcome back everyone to The PCOS Revolution Podcast. I’m excited today to have with me Dr. Aviva Romm, who’s a midwife, herbalist and Yale-trained MD, board certified in family medicine with obstetrics, who has been bridging the best of traditional medicine with good science for over three decades. Her focus is on what she calls our total health ecology using episome medicine to identify and reverse the root causes of chronic health conditions, particularly hormonal problems and women and common children’s health problems. She’s considered one of the world’s leading botanical medicine experts, and is the author of seven books on natural medicine including the textbook, botanical medicine for women’s health, and the adrenal thyroid revolution. Dr. Romm is author of the integrative medicine curriculum for the Yale internal medicine and pediatric residency, is on numerous scientific advisory and editorial boards, and is a widely sought engaging speaker. Her online programs for women are also wildly popular and successful helping women take back their health affordably and her innovative professional programs are educating and next generation of health practitioners. So welcome, Dr. Romm. So excited to have you here.

Dr. Aviva Romm

Thank you. Please call me Aviva.

Farrar Duro

Okay. Hey, and so you practice in New York City, correct?

Dr. Aviva Romm

Yeah, I’m in New York City. And then I also have a telemedicine practice, based out of where I live, which is Massachusetts, I’m in Western Mass in the countryside. I live on a little dirt road.

Farrar Duro

Awesome. Oh, great. Okay, and what really inspired you to go the natural route? Because having both the degree in midwifery right and being an OB that’s really interesting. So what what led you to that path?

Dr. Aviva Romm

Yeah, so um, I actually started out on the natural path when I was 15, I had a really early inspiration to become a physician and I went to college when I was 15, to become an MD, but then during that first semester, I got exposed to so many things that kind of just really transformed the rest of my life. I got exposed to herbal medicine who knew such a thing existed. Ironically, I in my 20s, I found out that my great grandmother was actually an herbalist. She was Hungarian, and I didn’t know that. But at the time, it was so new to me and I started to explore the role of diet and lifestyle and environmental exposures on our health. And so I started to actually change my diet. At that time I became a vegetarian and a vegan, this was back in like 1981. And started to notice that, for example, weight that I had gained during my very stressful transition from high school at 14 to college at 15. Just sort of automatically resolved without me having to quote unquote, diet or exercise, more lifelong allergies I had, which were pretty significant seasonal allergies were gone, I used to get sick and take antibiotics a lot. Now, I’m 53, I’ve taken an antibiotic one since I was 15 years old when I change my diet that way.

Dr. Aviva Romm

So I started to get really interested in natural approaches. And then I got exposed to midwifery. And the two really went so naturally hand in hand, because women who were looking for a healthier, more natural way to birth, also wanted more natural approaches for their hormone health or their fertility or once they had kids for their children. So it kind of just became a whole life style and profession for me. But ultimately, I couldn’t get any of that training in conventional medicine because back in 1981, the term integrative medicine had not been coined. Nobody was, you know, my family thought I joined a cult because I was doing all these weird things, which of course, I had not done. And so I had to really seek out this training. In the very few books, there were like three or four books on herbal medicine on the market at the time, there was one book on midwifery or natural birth at the time. So I had to find people in corners of the country that were doing these things and apprentice sort of the old-fashioned way. And then I did that for over almost 25 years, where I, not apprenticed, but worked with women and kids around natural medicine and birth. And then decided that I really needed to be part of changing the medical system and being a voice of sanity for people who also had to go into the conventional medical system.

Dr. Aviva Romm

So I went back, finished my prerequisites for medical school, because I had left school at 16 to pursue these other things. And then really went to med school and then pursued, I did my internship in internal medicine. So I’d be able to do all adult medicine and encompass things like I mean everything from psychiatry to immunology to oncology, but wanted to bring back that pediatrics and midwifery care. So I did my internship in internal medicine and my residency in family medicine. And that was where I incorporated the obstetrics piece because as a family doctor, you can do family medicine, with or without obstetrics. And I chose to do it with obstetrics. So kind of the whole the whole way it happened. And I’ve just continued to incorporate the same nutritional botanical lifestyle, ecological awareness into what I do as a physician. And I always try to go to that first. Not that I shun using conventional therapies when they’re needed, there’s a time and place for medications for surgery, etc. But usually, that’s further down the line. And there’s so many natural approaches we can take first that are safer and healthier and often as or more effective.

Farrar Duro

Very cool. And I got that, you know, today we will talk about pregnancy with PCOS, because a lot of focus is always on getting pregnant, and yet, there’s not a whole lot on pregnancy and postpartum. And even less on, you know, menopausal, perimenopausal women with PCOS. So, we do get a lot of questions regarding supplements during pregnancy and, you know, also working with around balancing blood sugar and that sort of thing. If you’re already taking something, should you still take it and all that. So I thought that we could talk today about that. And I know that our listeners have a lot of questions about this. So could you just give a little bit of advice that you have a great blog post on your website about natural strategies for PCOS? And if you do have a patient who’s pregnant or with PCOS, do you have any suggestions for that patient? That would be a little different, or what would you look at?

Dr. Aviva Romm

Yeah, so for pregnancy? You know, it’s interesting. First of all, I just want to step back and say, women with PCOS have historically and sadly continued to be fat-shamed, right? There’s this perception that women have PCOS, because they’re overweight, which also is a problem because a lot of women who are thin, who can still have PCOS also get their diagnosis completely missed. So there’s been a lot of misconception and misperception in the medical literature about weight and fertility and conception and ability to conceive. And actually, would you really dissect the medical literature. Just because you’re overweight does not mean that you’re more likely to have conception problems.

Farrar Duro

If you’re obese, if someone’s BMI is you know, over 30, then there can be more medical problems in general for anyone but just being overweight does not equate to a fertility problem. Similarly, you can be really slim and have PCOS and struggle with fertility problems. So getting to the crux of the matter. What we really want to think about or what I think about with PCOS, and getting pregnant, is is a woman ovulating. One of the biggest reasons that women don’t get pregnant pregnant is an ovulatory infertility, they’re not ovulating and one of the biggest problems with PCOS that leads women to have irregular menstrual cycles. And with that, sometimes fertility problems, which may be the first hint that there is PCOS, a lot of women have not had a proper diagnosis. Sometimes a woman’s been on birth control pills, it should have been recognized as soon as did most goes off the pill and now is struggling to get pregnant. I see that a lot in my practice.

Dr. Aviva Romm

So a lot of times, women don’t even realize that they have PCOS and the first sign that they have a PCOS is that they have trouble getting pregnant. A lot of times what I see in my practice, someone’s been on the pill, for example, since they were 14 or 15. It may have even been that they had symptoms of PCOS, but nobody noticed it because they had irregular periods, which is common when you’re a teenager, or they had acne, which is common when you’re a teenager, they were a little overweight, which people say oh, you know, you’re a teenager, and your hormones kicked and you gained weight. So they go off the pill. And then they try to get pregnant. And they’re having no six months, a year, two years. And it turns out, they’re just not ovulating properly. And so this is the biggest thing that I tried to give attention to, with women who are struggling with fertility and an ovulation, is looking at is it PCOS, then let’s get a proper diagnosis going. And if it is then working with their body to either address the excess testosterone, which is often what’s preventing the preventing ovulation, and making sure that their insulin and blood sugar levels are healthy.

Dr. Aviva Romm

Not all women with PCOS have measurable insulin resistance, but it is a really common problem, about up to 70% of women with PCOS have insulin resistance. And what’s interesting is that not all women with PCOS have detectable insulin resistance, but they may be more sensitive to insulin than other women. So they may still have some of the problems that come with it like this high testosterone. And the problem with this is that once they do get pregnant, well, if they struggle with the fertility problem, of course, that in itself can be excruciating, emotionally financially costly, taxing of time, then once women with PCOS do get pregnant, they have a higher rate of miscarriage. And that’s, you know, of course, very emotionally stressful, and often have if they have an insulin resistant or blood sugar problem with their PCOS, run the risk of having problems like gestational diabetes, when they’re pregnant, premature labor when they’re pregnant, and babies with higher levels of problems. So, I don’t want anybody listening to be scared about that. It’s just important to of course, be educated and knowledgeable and most OB/GYNs and family doctors are absolutely not knowledgeable about the connection between PCOS, miscarriage and pregnancy problems.

Dr. Aviva Romm

So when I have a woman who is coming in for prenatal care for fertility care, or for PCOS, and she’s thinking that she might want to get pregnant sometime. I always want to make sure that I’m working with her to optimize her blood sugar, making sure that her blood sugar levels are ideal, and healthy before she gets pregnant, usually just working with diet, and then working to make sure that we’re addressing her testosterone levels, which you don’t necessarily always have to keep testing and testing and testing. But you can often look at is that excess hair that is growing in places she doesn’t want it not growing anymore, is she having continued acne. And as those symptoms start to clear up through work with diet, sometimes supplements, you’re kind of getting the physical signs that things are improving. During pregnancy, it gets a little bit trickier because one we can’t easily diagnose PCOS during pregnancy.

Dr. Aviva Romm

So if you didn’t already know someone has it, you know, you may be kind of walking into that not knowingly, but it’s really important during pregnancy for women to keep their blood sugar really healthy. And also, if someone goes into to pregnancy on a lot of the PCOS supplements that are recommended, and particularly the botanicals, not all of those are safer use during pregnancy. So it’s important to have a really good plan in place. If someone has had problems with their blood sugar, you know, how are you going to keep it steady? If the only way you’ve achieved keeping it steady before is with you know, certain herbs and supplements, you know, and then just being aware of blood sugar throughout pregnancy and making sure that you’re staying on top of preventing gestational diabetes, which is really quite possible with a healthy diet.

Farrar Duro

And would you recommend Myo inositol powder during pregnancy?

Dr. Aviva Romm

I recommend Myo inositol, it is actually proven safe for use during pregnancy. So it’s one of the it’s one of my definite go to supplements for women who are who are struggling with preconception problems or you know fertility problems, who have PCOS in general, particularly if they have a known blood sugar problem. And interestingly, I’m at least in one study, combining Myo inositol with folic acid, which is actually really important for preconception and baby’s health, even before you get pregnant, but certainly during that first trimester as well, has actually shown to improve conception rate of improved ovulation and conception rate in women with PCOS even better than Metformin, which is the standard medication use for blood sugar regulation. You can also use D Chiro inositol, or you can use a combination of the Myo inositol and D Chiro inostiol.

Farrar Duro

Very good. And do you have any recommendations as far as you know, probiotics or vitamin D level, what type of vitamin D or anything like that?

Dr. Aviva Romm

Yeah, so vitamin D is both essential for a healthy pregnancy. And also, we know that moms that get optimal levels, or moms who have optimal vitamin D levels during pregnancy, actually have babies with healthier dentition, their teeth are better when they when they get their teeth. So it’s really important to keep your vitamin D levels healthy during pregnancy, I like to see vitamin D levels between about 50 and 80 on bloodwork. And for most people, even if you don’t know what your vitamin D level is, taking 2000 international units of vitamin d3 during pregnancy is totally safe for pretty much everyone. There’s one rare exception, which is one particular autoimmune condition that’s so rare.

Dr. Aviva Romm

But for everyone else, it’s really, really safe. So I recommend that 2000 units for all my pregnant women. But I usually do a vitamin D level on my women with vitamin D with a PCOS. And if their vitamin D level is below 40, then I will always be supplement to try to bring them up to at least 40. Usually 2000 units a day, if someone’s in a healthy range will keep them in a healthy range. And if they’re below a healthy range, so anything under 20 is considered deficient. Anything under 30 is considered insufficient. 40 is really an optimal level to start, you know to get to. So if they’re below those optimal levels, I will supplement more sometimes 4000 or up to even 6000 units a day. I don’t recommend just doing that on your own, though, that’s when it’s really good to work with an integrative family doctor who’s trained in obstetrics or an integrative ob/gyn or in a knowledgeable midwife to help get you to that right level because you want to retest if you’re at those high levels to not keep taking those sustained high levels, once you reach a normal blood level.

Farrar Duro

That’s great advice. And I feel like they’re two I guess, roadblocks when that I’ve noticed with our patients. And also myself when I when I was pregnant. If you have irregular cycles, sometimes a typical gynecologist is going to base your due date and all everything on, you know, a normal cycle and a 28 day cycle, I guess you could say. But if you’ve had 36, or 40 or 50 day cycles, that’s your norm. You’re ovulating much later. So they could actually potentially tell you that, you know, you’re not doing well the pregnancies not going as well as it should have, you know, your numbers aren’t where they need to be, if they’re basing it off of, you know, 28 day cycles. So, so I think, you know, we tell them, you know, make sure that you tell your doctor about your long cycles. So that that doesn’t, you know, happen, even with an ultrasound a heartbeat, not there. And it’s like, wait, it’s only five weeks. So typically,

Dr. Aviva Romm

if somebody is having like a 40 or 50 day cycle, often not itself has been an anovulatory cycle. So typically like that, you wouldn’t necessarily give like an extra 30 days. But I agree with you erring on the side of two weeks plus or minus is really important because one, ultrasounds can be inaccurate by two weeks. And a lot of times we’ll see somebody who gets induced too early, because they’re, they’re told that they’re going overdue when they’re not necessarily overdue, they just conceived later. The other thing is that women who have higher body weight are often going to be flagged by the medical model as being much higher risk. And that’s not always the case with significant obesity.

Dr. Aviva Romm

It’s the case and with diabetes, it’s the case with gestational or, or non gestational diabetes, it’s the case but just being overweight, doesn’t mean you’re more likely to have really severe pregnancy outcomes. And doesn’t mean you need to be induced. So women need to advocate for themselves if they feel like they’re being treated based on their weight or fat shamed and really important, because this is actually a very big problem in conventional medicine.

Farrar Duro

That’s true. And I was thinking the other thing would be anemia. Because if you have high, I mean, if you have, you know very long cycles or heavy cycles with a lot of women do with PCOS, once they get their period, you know, then also you have a higher chance, you know, also when you’re pregnant of having anemia, so that’s important to talk about. So would do, would you recommend women getting their ferritin levels tested also, I mean, is that a typical thing to get tested during pregnancy?

Dr. Aviva Romm

It is in my practice. So hemoglobin and hematocrit are the standard of what is included in prenatal lab work. So you get a complete blood count, you’ll get a whole bunch of prenatal first trimester labs, usually, and hemoglobin and hematocrit are markers of how much oxygen carrying capacity your red blood cells have. But they’re not that accurate for looking at over iron deficiency anemia. So correct, you want to get a ferritin level. Because ferritin level is going to be a much more accurate picture that that demonstrates what your iron stores are. So you can have a normal hemoglobin and hematocrit and be kind of borderline and your doctor is going to be like, Oh, that’s normal, because pregnant women often have lower iron. And that’s sort of true. What happens in mid trimester is this phenomenon called hemodilution, you get more blood volume.

Dr. Aviva Romm

So anytime you get more volume, whatever is in that it’s going to be diluted. And so it looks like you have lower levels, but you shouldn’t be too low because it can really have an impact on how you feel. But you could have borderline normal hemoglobin and hematocrit, your doctor say, Oh, that’s fine. But if someone to check your your ferritin, and they would see low iron stores, and low iron in pregnancy can, or anytime, even when you’re not pregnant, can make you feel really miserable. It can make you feel exhausted, have shortness of breath, it can affect your appetite, it can increase your nausea, it can give you restless leg syndrome. So a lot of things that we think of as kind of quote unquote, I’m doing air quotes here, you guys who are listening can’t see me but quote unquote, normal for pregnancy, like a lot of these quote unquote, normal discomforts can actually be symptoms of sort of underlying hidden iron deficiency anemia or other nutrients as well, because iron deficiency anemia, is often goes hand in hand with other nutritional deficiencies.

Dr. Aviva Romm

But yeah, PCOS because you’re not ovulating, what happens is, you have this longer build up of the uterine lining. And because you don’t get that ovulation, you don’t get that progesterone and you don’t get that normal cyclical drop in estrogen, and progesterone, that makes you have a flow at 26 or 28 or 32 days. So you can be building up this uterine lining for four weeks, six weeks, eight weeks, you know, as you said, Some women are 50, 60 days, I’ve had patients who have come in and haven’t had a period in six months. And then when you finally get that period, for some women, it’s just such a gusher. And this can be happening every few months, and you can really get depleted.

Farrar Duro

And besides taking iron would I mean, some people don’t like taking iron, because it makes you constipated, what would you recommend, are there any favorites? I guess, iron supplements that you like, or are any other alternatives?

Dr. Aviva Romm

Yeah, so I have a few different things that I do for iron. It depends on how severe the iron deficiency is. So if someone is really exhausted, they’re very symptomatic, their heart is racing, they’re anxious, you know, they just are pale, they’re really showing signs of anemia, then I will always bump up the diet to include more iron rich foods. So iron rich meats, red meat, dark meat, Turkey are good sources, but also vegetarian and you know, vegan sources are really important. So leafy greens, for example, legumes, those are all important resources as well. It’s a little bit harder just as a vegan or vegetarian if you’re already deficient, to get up to a high enough level really quickly. So often encourage patients, if you’re really deficient to you know, just try a little red meat and dark meat, poultry for a while and then go back off it. But if they won’t, that’s okay, too. But even if they’re eating meat, and they’re really, really symptomatic, or their levels are super low, I will add in a chelated iron.

Dr. Aviva Romm

So chelated iron is actually specially bound in a way that makes it more absorbable, and it tends to not be constipated. So any number of chelated iron products work really well. I keep a formulary over on my website where people can look and see what different supplements that I do offer to my patients, but a standard, any standard related iron is going to be fine. And I usually recommend a 30 to 60 milligrams a day of iron to really bump things up. And I think that the chelated is such a better form because it doesn’t cause constipation. But if you can’t tolerate iron ore if your iron isn’t, if you’re not that deficient, you can start with diet. I’ve also used things in my practice like black strap molasses and as an herbalist, I do a black strap, molasses, dandelion root and yellow dock root combination. I’ve got that recipe over in my book, the natural pregnancy book.

Dr. Aviva Romm

And it’s been amazing how many times I’ve had women write to me, you know, women, I don’t know, but they’ll write in and they’ll say, my doctor, my midwife tried everything to get my iron up and nothing was working. And I did this combination of herbs and black strap molasses and it was amazing. My iron came up in like three weeks. And I’ve seen that in my own practice. The nice thing about those herbs too is they help with constipation. So black strap molasses, it does have some sugar, so you want to be careful if you have insulin resistance or gestational diabetes, of course you want to talk with your midwife or your your OB or family doc about using it, because it does have sugar in it. But it’s a highly observable form of not only iron, but calcium.

Farrar Duro

Very nice. And I know I’m on your your blog that you’re writing about your supplement recommendations for PCOS, you mentioned daily probiotic. So I would say that would still be okay during pregnancy?

Dr. Aviva Romm

I recommend a probiotic during pregnancy for a couple of reasons. The reason I recommend a probiotic with PCOS is two reasons one, probiotics, particularly if you have an overall healthy digestive system, the microbiome has this whole special branch summit called the estrobolome. And the estrobolomes job is a group of different organisms whose entire job is to make sure that you are breaking down and eliminating excess estrogen. And one of the things that happens in PCOS is that some of that excess testosterone actually gets converted to estrogen. So we think of PCOS as a problem of excess testosterone. But it actually also contributes to an overload of estrogen. So the probiotic can help that estrobolome to metabolize and get rid of some of that excess estrogen, taking flax seeds, two tablespoons of flax seeds daily ground up, you can just take it in food or a smoothie also helps with the estrobolome and getting rid of that excess estrogen. And it’s also really beneficial because it’s super high in fiber. So that can help with pregnancy constipation. The other thing we know about healthy microbiome is it actually helps to keep blood sugar stable. So it’s not just what we eat.

Dr. Aviva Romm

But the health of our microbiome determines how we well we are metabolizing our sugar, and how and it can help to affect insulin resistance. So I include a probiotic, because it’s safe during pregnancy, for those reasons. And then also, unfortunately, right now, in the United States, 34% of all women who have who have a baby will have a baby by C section. And there have been some studies looking at taking a probiotic in the third trimester when you’re pregnant, helping offset some of the microbiome risks for baby. And the long term risks of that for babies who are born by C section. So it seems like for me a worthwhile safe preventative approach. And it’s, you know, probiotics can be gotten affordably, you can also use lactose fermented foods in your diet. But typically, I recommend a probiotic that has a combination of lactobacillus and bifida bacteria and strains, and at least 10 colony 10 billion colony forming units as a baseline dosage.

Farrar Duro

Okay, that’s great. And, and, you know, picking your brain here, but I really like NAC, N-acetylcysteine for PCOS. And you know, the research I’ve read is that, that it can be helpful during the first trimester. But I know that we’re also very hesitant to recommend a lot of supplements if unless they’re really needed. So, what is your view on that?

Dr. Aviva Romm

I feel like the data on NAC in first trimester and in pregnancy is a little less robust. So, I do also recommend it, I would say of course check with your primary provider before using it and make sure that you know, they support you in the use of it. You don’t want to lose your primary provider because they think you’re doing wacky things and keep it to the lower end dose. So the typical dose of NAC in pregnancy, the typical dose of NAC outside of pregnancy is up to 900 milligrams three times a day. in pregnancy, I keep that closer to 300 milligrams three times a day. And I will often wait until after the first trimester for things that have less robust evidence for them. But NAC is something our body is producing naturally, all the time. So I’m I’m comfortable with it. Whereas some of the other supplements that I recommend on my podcast like PME and licorice, black cohosh, even l-carnitine, I find the data is less and I’m less comfortable with it during pregnancy.

Dr. Aviva Romm

And NAC has so many benefits too, even there’s one that shows it prevents miscarriage. And so I thought, you know, if someone is using it for with PCOS, for balancing their insulin levels, and helping with keeping on reducing testosterone levels and all that, for unwanted hair growth, that sort of thing, and they are kind of hesitant to stop, then that’s something that you should have a conversation with, with your provider. Definitely. But But yeah, I mean, like I said, the research is there’s just, it’s hard to do research on pregnancy.

Farrar Duro

Impossible. Yeah. And, and you know, I think one of the things about pregnancy is that some of the because of the super high levels of estrogen during pregnancy, some of those testosterone dominance symptoms will be a little bit more subsided during pregnancy. But the blood sugar balance is so critical during pregnancy, because that is what can really have such a huge impact on baby too.

Dr. Aviva Romm

Right? And so I guess with you know, if you if you’re taking the D Chiro inositol, or Myo inositol combination, and you’re eating, you know, regularly with balancing protein and fiber intake and that sort of thing and reducing sugar, then that’s because those really helpful satiety and yeah, then you might not need the supplements. But, you know, there’s, and there’s conflicting research about Metformin during pregnancy. So what do you think of that, because I just feel like every week, something different comes out. It’s helpful, helpful, it’s like, amazing, it really is.

Dr. Aviva Romm

So my, my approach to pregnancy is always to work with diet first, unless someone is frankly, diabetic or has significant insulin resistance, in which case, I will often go, if it gets to the point where we’re now talking about gestational diabetes, or Frank diabetes, then I actually think that truly insulin is the safest drug to use, because it’s so tried and true. It’s replacing what your body naturally needs. And so I actually think working with your primary provider around insulin, because we know it’s safe, may actually be preferable to any of the other medications during pregnancy.

Farrar Duro

It’s interesting. And I mean, is there a point where your body says, well, you’re giving it to me, so might as well not make any more of it? is still gonna work? Okay, if you if you come off of it?

Dr. Aviva Romm

Oh, yeah, really the only thing that really our body say I’m not going to produce anymore if you give it to me is cortisol. But with insulin, absolutely. I’ve had people who are diabetic for years come off of insulin completely working on natural medicine protocols. So you can come off of those medications with just getting your blood sugar unless your pancreas has completely quit. You know, you’ve had a disease that damaged the pancreas so much that it can’t produce insulin, autoimmune pancreas, pancreatic disease, for example, type one diabetes, then no, you wouldn’t be able to come off of it.

Dr. Aviva Romm

But for everyone else, you can use it as just a temporary measure. I mean, for example, when I have had patients in the hospital who have severe infections in the ICU, and we put them on cortisol, because of a severe systemic infection, sepsis, something like that. Often, because of that high cortisol, their blood sugar goes up. And so we have to put them on insulin, they basically become temporarily diabetic. So we have to put them on insulin, just till the disease process has past and they’re off the cortisol, and then they come right off of the insulin.

Farrar Duro

Very neat. So definitely, that you don’t you don’t want to get to the point where your gestational diabetes is showing up. But if it does happen, then you know, it is is pretty common with PCOS too. Would you recommend someone saying to their, you know, I, I think I remember, you know, getting the glucose tolerance test done around week 18, or 20 of the pregnancy, would you, we talked to the nutritionist earlier in the program that was saying, Hey, what about if you got that checked a little bit before that?

Dr. Aviva Romm

You can get a hemoglobin A1c done at anytime during your pregnancy and hemoglobin A1c is it measures something called glycosilated, red blood cells. And what that means is that when you have sugar in your blood from high blood sugar, like insulin resistance and hyperglycemia, the sugar actually starts damage and bind to the red blood cells. And so you can get this test that measures the impact of sugar on your blood cells over a three month average. And so anyone who’s in preconception phase, and anyone who has just anyone who has PCOS, before they get pregnant, it’s really worthwhile to have a hemoglobin A1c, it’s much more accurate than just getting a fasting blood sugar. Because the fasting blood sugar, if you fast overnight, it’ll be normal or low. If you’ve eaten a high sugar meal, it’ll be high. Whereas this A1c gives you an average over three months, it’s a little bit hard to fake that out, if you will.

Farrar Duro

And what number would someone be looking for, ideally?

Dr. Aviva Romm

Ideally 5.4, or below to, like 4.8 to 5.4, you want to be too low, and they’re not getting enough nutrition, but up to 5.6 is considered normal. Above that, you start to get into what’s called pre-diabetes. And there can also be metabolic syndrome associated with that, which can have high blood sugar, high cholesterol, overweight, other symptoms. But once it starts to get to over 5.5, it can creep up to 5.6 and 5.7 pretty quickly. So 5.5, I wouldn’t, you know, I wouldn’t call the fire department. But ideally keeping it at that 5.4. Below, you’re really in a great zone. It’s not the standard test during pregnancy, but it can be done during pregnancy early on, you can definitely get a blood sugar test earlier on in pregnancy and not wait until mid pregnancy to find out that the horse is already out of the barn.

Farrar Duro

I was wondering why they did at that point. Yeah, I think it’s a little late.

Dr. Aviva Romm

Not even all European countries do the testing the same way we do it. A lot of controversy around it. And I agree it’s it’s a little like postpartum care waiting till eight weeks postpartum for your six weeks postpartum for your first postpartum visit is crazy, right? You’ve already missed the window on breastfeeding and postpartum depression support and all that. It’s not medicine is not always the most sensible, sensible guidelines that are offered. So yeah, you can get checked earlier. The main thing is having that really healthy prenatal diet from the beginning. And it’s tricky, right? When I know that when I was pregnant with my kids, it’s like, first of all, I had no appetite, then I was nauseated. And then the only thing I really wanted was carbs, you know, and we get this idea when we’re pregnant. I think this goes back to like the 50s, that you’re pregnant, and you’re eating for two.

Dr. Aviva Romm

And so we kind of go all out and feel like all right, well, I’m pregnant, I’m eating for two, I feel kind of nauseated, I’m just going to eat whatever. But it’s not actually true. We don’t need to eat for two until maybe like the middle of the last trimester of pregnancy unless you’re pregnant with twins. And then you do because your caloric and nutritional needs are higher. But our nutritional needs during pregnancy do not go up at all, during the first trimester, they go up a caloric needs do not definitely do not go up at all, they go up a little bit during the second trimester. And then by the third trimester, you only need about 300 more calories a day than when you weren’t pregnant at all, this is really not that much pregnant, again, twins, and more is different, you need more. So you know, being mindful to not just use pregnancy as an opportunity to just sort of throw your diet to the wind and say whatever, I can eat as much as I want now. And then you know, it does. It does sort of quell nausea to have carbs, but to make sure that you’re still getting those good quality fats, good quality proteins, not just going for the sugar.

Farrar Duro

Definitely, that’s great information, because I feel like we should we have so much to talk about. And I know we’re like getting to the end. But I want to I want to get in a question about the fourth trimester. Because there’s some anxiety I’ve noticed with our patients to about waiting for that first period to come. So you know, after the breastfeeding is done, or if someone’s not breastfeeding, because they’ve had such irregular cycles, they think, okay, either it’s going to go two ways, my period will become regular, magically, after I deliver or it’s going to be back to those like six months a week, you know, as far as when, when the cycle appears again. And there’s a lot of fear around that.

Dr. Aviva Romm

I just went through this with one of my pregnant mamas who had PCOS, she got diagnosed with infertility, kind of was on the edge of fertility treatment, came to me worked with me also worked with an acupuncturist, got pregnant, actually, within a few months, had her baby, and then was breastfeeding. And she was breastfeeding full time for the first six months. And she went back to work and then was pumping. And then because of breastfeeding, her period was depressed. And she went through exactly that, like, is this PCOS? Should my period be back?

Dr. Aviva Romm

When’s it going to come back? And it was actually about a year and change like maybe 14 months when she finally wasn’t breastfeeding anymore. And then it was like a couple of months more. So she stopped breastfeeding in a year. And then a couple of months more, her period finally came back, we actually did approach protocol of some vitex and a supplement called Ovasitol. But it really was just a matter of her waiting for her period to come back post-lactation, which was so normal, but it is so nerve wracking. But I think you kind of have to just trust your body. If you’re breastfeeding, you can experience what’s called Lactational amenorrhea, you know, the whole time you’re breastfeeding, and then some. So that’s pretty normal. I would always as I said to my patient, you know, the jury’s out until the jury’s in. And so until you’re not breastfeeding anymore, we really don’t know. And it’s so difficult because labs, while you’re breastfeeding aren’t going to really tell you very much that’s useful anyway. So, you know, getting labs tested during that time, isn’t, isn’t worthwhile.

Farrar Duro

Sure. And I think the depression sometimes can kick in about “this weight that I’ve gained during pregnancy is not coming off.” And that can be for anyone, but especially with PCOS, it seems like, you know, it’s it’s a little harder sometimes to kind of recuperate, and that way of getting back to where they were. And obviously, it could take a year or two, I mean, you have to give your body some time. It’s not like the magazines, where they’re like, oh, six weeks, and they’re like back in a bikini.

Dr. Aviva Romm

You’re like, I’m trying to think of who but some, you know, celebrity if you’re Jessica Alba and have a bunch of kids, but you have a personal trainer and a chef and you know, millions of dollars sitting in the bank, obviously, your stress level and your demands are going to be different than most of us who have to get up and take care of our own babies and go back to work and have to cook our own food or somebody, you know, maybe a partner or family members helping but it’s very different. And just having that personal trainer and that chef can make a huge difference. I think that you know, if you’ve struggled with weight with PCOS, before even gaining weight during pregnancy can be very stressful.

Dr. Aviva Romm

So it’s just sort of a matter of trying to trust your body and hope that, you know, you can actually reset some patterns while you’re pregnant, and then just wait and see what happens afterward. And certainly women with PCOS are much more prone to depression. So if you’ve had a baby and you’re experiencing depression, don’t just chalk it up to baby blues, or don’t just chalk it up to this is normal and I’m exhausted, but actually seek help. The other thing that’s really important to remember is that postpartum thyroid problems, postpartum hypothyroidism is quite common, it’s much more common than most doctors will check for. And the other thing with that is that there is a period of time postpartum, where you can feel the symptoms of postpartum depression and low thyroid. But if you go and get your labs check, there’s a window in which the labs might look normal. And I have a whole podcast about thyroid and postpartum over on my website, and my it’s a blog and a podcast. So listeners who want to learn more about that can, but it’s really important to get your thyroid checked, go ahead and get you can get a hemoglobin A1c done after you’re pregnant, look at what your blood sugar is, but get help, you know, whether it’s depression from PCOS, an inflammatory changes, hormonal changes, or thyroid, trying to go that alone is it’s too much I would say being postpartum is like pushing a piano up a hill, being postpartum with depression is like pushing a piano up a hill holding your baby with your hands tied behind your back, it’s just you can’t do that alone.

Farrar Duro

That’s a great analogy. And I know that, you know, sleep is also you know, an issue as well, sometimes postpartum. And that just kind of exacerbates everything when you’re not sleeping and your adrenals are already shot going into the pregnancy.

Dr. Aviva Romm

And then your cortisol makes you pack on weight, and it throws your hormones off. And the other thing we didn’t talk about, which is really a hidden phenomenon is the number of women with PCOS who have sleep apnea. And that in and of itself can also get exacerbated by pregnancy with increased pressure on the diaphragm increase weight, that’s just normal from pregnancy, increased engagement of the tissues, the nasal airway can make that worse. And so that can drive high blood sugar, it can drive daytime fatigue, and it can drive high blood pressure during pregnancy and be a risk factor for prenatal hypertension.

Dr. Aviva Romm

So if you’re, if you’re planning to get pregnant and you have PCOS, even if you’re not planning to get pregnant, you have PCOS, it’s actually really worthwhile to get a sleep study done. particularly critical. If you have depression, daytime fatigue, or high blood pressure. But if or if you snore, if you have sleep apnea symptoms, absolutely. Like you get morning headaches, you wake up during the night, and you’re kind of like, you know, you gasping for air or you have your partners if you sleep with a partner who says you know, you have a few episodes at night where you’re kind of sounding like you’re not breathing, those can all be symptoms of sleep apnea. And I actually have a podcast coming out just about sleep apnea and PCOS.

Farrar Duro

Oh, that’s wonderful. Well, by the time this episode comes out, we’ll definitely have that link to in the show notes. And I think that, that’s great that you brought that up, because some people feel like it’s hard to get that sleep study or and then once they get it, they’re afraid they’re gonna have to wear a see pop or something bulky, that they’re not aware and all that. So is there any thing that you know, that’s out there that newer that that might be helpful?

Dr. Aviva Romm

Actually an oral device that can be whose I think it’s sleeping with a mask is so intimidating for people, I will say that the patients of mine who have done it, who have sent in quite a number of patients every year, I send in a few patients, at least for a sleep study. And it’s amazing, they’re usually positive. And it doesn’t matter what their weight is, but it’s just so common. And so under tested for, and they’re afraid to wear this mask, it feels claustrophobic. But the ones who do it and are able to stick with the mask are like, Oh my gosh, Dr. Aviva, this is like night and day, I feel like somebody switched the lights on in my brain, and I’m functioning again, and I’m sleeping again. And I don’t feel tired all day. And you know what happens when you’re tired all day, you crave sugar, you crave caffeine, so so many things come in line. But if you’re just not able to tolerate it, there is an oral device that kind of shifts the way your jaw is set. And any sleep specialist can help fit you for that. And most people find it find that a decent alternative to the C-pap.

Farrar Duro

Oh, that’s utterly encouraging. Well I think, are there any home devices that can measure your sleep or not?

Dr. Aviva Romm

You can actually do an at home sleep study, you don’t get all of the same measurements. So I think that the clinical sleep study is probably a bit of a better study more comprehensive information. But it’s going to a sleep clinic just feels too anxiety provoking for you or you have little kids at home and you don’t feel like you can do it whatever reason, then you can do these at home sleep studies. And again, a primary care provider can write a referral to you for a sleep specialist. And then that sleep specialist can order the home or the in clinic in the sleep Sleep center sleep study center test for you.

Farrar Duro

Well, I know that the the university near our office definitely conducts these, they have a whole department for that. So you know, you can look it up and find you know, some of these near you. And I think that’s very helpful information. Because if you’re not sleeping, it’s just like, everything else is just, it’s like going uphill. I mean, it’s very hard with it doesn’t matter what supplements you’re taking.

Dr. Aviva Romm

You cannot fix lack of sleep with anything but sleep. I mean, it’s so true. I mean affects our diet, it affects our choices, it affects our mood, it affects our safety, it affects our hormones, every day. Definitely.

Farrar Duro

So, to summarize it, definitely, it’s good to be proactive, and, you know, asking for a few labs that might not be recommended, in general, because everybody’s different. So if you have PCOS, vitamin D and Ferritin, and, also looking at the A1c is important. So all those are good, and they might not be offered to you, especially in the beginning and your thyroid, like you said.

Dr. Aviva Romm

And I know a lot of women don’t want to get the glucose tolerance test when they’re pregnant. But if you do have PCOS, it’s definitely indicated. So that is one of the times and I’ll absolutely say yes, please do get the mid pregnancy, the glucose tolerance test as well.

Farrar Duro

Definitely. I mean, I feel like this has been so helpful because we get so many questions around pregnancy. And it’s like the biggest complaint is, well, there’s just not enough information out there for pregnancy. And with PCOS, especially, so I really appreciate you giving us these tools to work with and, and I want to encourage our listeners to go to your website. Also, to check out, you can do a search for PCOS. And you’ll see all the articles on Dr. Aviva’s website so you can really get that information that we talked about today as well. And of course, we’re going to link to that as well as a link to your podcast. So, so I really appreciate all the time you spent with us today. And thank you guys for listening. Take care of yourselves, everyone and we’ll see you back next Tuesday. Have a wonderful week.

Episode Spotlights:

  • How Dr. Aviva got started ([1:44])
  • Conception issues and PCOS ([8:15])
  • Supplements for women struggling with preconception problems ([14:45])
  • Vitamin D levels ([16:52])
  • Anovulatory cycles ([18:55])
  • Eating an iron-rich diet ([23:50])
  • Typical dose of NAC ([29:45])
  • Breastfeeding ([38:38])
  • Gaining weight with PCOS ([42:14])
  • Women with PCOS and sleep apnea ([44:20])
  • The importance of sleep ([48:08])

Resources Mentioned In This Episode:

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