Wardee: Hi everyone, welcome and welcome to my guest, Angie Nichols. Hi, Angie.

Angie: Hi, Wardee. How are you?

Wardee: I'm great. I'm so thrilled to have you back. We're just going to fill in a little bit of gaps here for our audience. Everyone, Angie is returning to talk with me about another health topic in case you missed it or want to refresh about a year ago, we discussed bio-identical hormones for women. And it's been wonderful. She gave so much information. And if you haven't yet, check that out a wonderful refresher, wardee.com/hormonepodcast, all one word. And now I want to tell you a little bit about Angie because she's returning to give us more information about a very unaddressed and undiagnosed but large problem that affects a lot of women. And it's PCOS, which she'll go into and explain that to us. But let me tell you a little bit about Angie.

Angie and her husband have a passion for health and wellness. Her husband is Dr. Keith Nichols. And together they have a practice called Tier 1 Health and Wellness, recently relocated to Chattanooga, Tennessee. And they worked on preventing chronic disease as well as maximizing health and vitality through proper diet, nutrition, exercise, appropriate supplements and bio-identical hormone replacement therapy when it's clinically indicated. Angie and I have been friends online for going on a year now. And at the end, we're going to share some stories with you of the great work she's done just in our audience. But I just want to welcome you again, Angie and have you tell us a little bit about you before we go into talking about PCOS?

Angie: Thank you so much for having me Wardee. It is my pleasure to be here. As you said, my husband and I started a bio-identical hormone replacement therapy program. About 12 to 15 years ago, alongside his spine and sports practice, we started it because of our own personal experience. We had difficulty finding help, and as two people in the medical field, if we were having trouble finding help, how difficult is it for someone in the general population with no medical experience. We did this alongside the spine and sports practice, and it just grew word of mouth, we have a passion for it. And we love the results and people's lives changing, their quality of health, quality of life. And that's really what it's all about. Over the course of the last 12 to 15 years, the practice has grown. And he recently retired from spine and sports, and we have devoted our lives full time to preventive medicine. And we're just really thrilled that we have the honor to be able to do that and to offer it to other people.

Wardee: Yes, amen to that. Do you want to tell us really quick a little bit about your personal experience with PCOS, and then we'll get into talking about what it is and more?

Angie: Sure. I have PCOS, I did not know that I had PCOS until about five years ago, never had any of the signs until later. And the reason was that I was always very active, very thin, all kinds of sports. You can't cure PCOS, but you can manage the symptoms. By having healthy lifestyle factors, then you can minimize the symptoms. With healthy nutrition, adequate activity levels, stress management, an adequate amount of sleep, all those things, you can really minimize the symptoms and control it that way. Most all of my life, that's how things have been. Well, as you start to age and you start having children and work and family life and all these obligations, a lot of us tend to slow down. And whenever we slow down and we aren't as active as we used to be, then the symptoms of PCOS become more evident. And so that's what happened with me, I was like, "Why can I not lose weight? Why am I having difficulty losing weight?" Just things that started to become more apparent.

The fatigue for me if as long as I was moving, I could do the things that I needed to do. But if I got still at the end of the day, like the drive home from work, it was so difficult to stay awake. I didn't know what was going on. And then the other thing was there was irritability, that was not me. I've always been very laid back nothing really bothered me. And all of a sudden, I would notice that little things that should not have bothered me all of a sudden seemed like a monumental thing. I went to my doctor and I was like, this is what's going on, what do you think? With the fatigue though it was so severe. I really thought that I had something wrong, could it be Cancer? You start trying to play out in your mind, what could this be? He looked at me and he said, "Angie, this is all hormone-related.

I don't have time to learn about all that. I'm busy delivering babies and performing a hysterectomy." We started this quest to figure it out. And we had been going into courses for hormone therapy for a few years. And it always interested me to go to the lectures on PCOS, just because I knew that if it wasn't addressed, the long term health risks were tremendous. But it wasn't really something that we had planned on trading in the hormone practice. We were just going to focus on age-related hormone decline. But for some reason, I was drawn to these lectures and so I started listening. And I kept telling Keith, this is something that we really need to address, we need to... and he's like, "No, no, we're going to focus on the age-related decline." But still, there was that pull that I need to learn more.

I started learning more about it, reading all the things that I could, attending courses. And just so happens then, I started seeing things in myself that I was reading about in the research. And so then we started doing a few tests and sure enough, it became clear, that's what's going on. Now, my daughter about the same time she was probably about 12. And I noticed in her some of the symptoms of PCOS even though she doesn't look textbook, what most people think about whenever they think of PCOS. It was the subtle things that I was seeing in her and we start doing some testing. And sure enough, that was what was going on with her too. And I'll get into more of the symptoms of what those things are, later on.

But, I started seeing it myself first, then I noticed it in my daughter, and luckily, we were able to address it with her much earlier. But I think the reason that we're seeing it also in younger people it's becoming more prevalent in younger girls, is just because of the world in which we live. They're more sedentary in general, computers and everything, they don't go outside and do things like they used to and being as active. And so we're seeing more and more hormonal issues, in not only younger women, but also in younger men. It's something that we all need to be aware of. Also, as we're living in a polluted environment, there are toxins everywhere, in the plastics, and just everything that we're exposed to on a daily basis. And it is having a tremendous effect on our reproductive health and just the hormonal system in general.

Wardee: We have a little bit of PCOS history in our family so I'm very interested in what you have to share today, I think it's going to help me and my daughters shed light on different things that we've been exploring and doctors have shared with us over the years for hormonal health. So I have a personal interest and I know a lot of our audience does in PCOS as well. Let's start by you telling us exactly what PCOS is, and then we'll go from there.

Angie: PCOS is the most common endocrine disorder among reproductive-age women. It is not only an endocrine or hormonal disorder, but it's also a metabolic disorder. It's characterized by high levels of insulin, and high levels of androgens, or male hormones. Approximately five million women are diagnosed with PCOS each year, one in five women are affected by this very complex endocrine disorder whose signs and symptoms and the severity of those signs and symptoms vary from woman to woman, depending on genetic factors and lifestyle factors. However, most experts agree it is greatly underdiagnosed, and it's estimated that the number of women undiagnosed could be as high as 70%. Now think about that Wardee, it is the most common endocrine disorder among reproductive-age women. And the lack of diagnosis could be 70% for women.

Wardee: Astounding. Which means that a lot of women need help.

Angie: Yes, yes, a lot of women are suffering, but they don't know what's causing it. I can't tell you the number of women that come in and tell us their stories and things they've gone through. And it's just so clear because we've been doing it for so long, that it is PCOS but they never get the help. And because of it, they suffer needlessly. One thing we'll go into is it's so sad when you see women who've come in and have multiple miscarriages, they don't know why or they could not get pregnant. And just had they gotten diagnosed early and got the adequate treatment that could have very likely been changed and change the course of their lives and their family lives. That's one of the reasons it's so near and dear to my heart and why I want to get the message out there for women to know that there is hope out there and there are options and not to give up.

Wardee: Angie, can you tell us what causes PCOS?

Angie: Well, the cause of PCOS has been highly debatable. There are many theories. And those have changed over the years as more research becomes available. But we know clearly that PCOS is genetic. As you know Wardee there have been tons of advances made in the last 25 years in the field of genetics. It was once believed that the genes for PCOS were only passed down through the mother. But now we know they have identified within the last few years, that genes associated with PCOS can be passed down from the paternal side. And there was a 2019 article that started a meta-analysis, where they actually identified 19 PCOS associated loci in the DNA. We know that it's genetic, there are also lifestyle factors that can play into it. But really, all of the signs and symptoms or the majority of the signs and symptoms associated with PCOS come from insulin resistance.

That's what we really have to address is reducing that insulin resistance. I'm going to try to simplify this extremely complex disorder. I'm going to... give you a slide Wardee that hopefully will, a picture's worth 1,000 words, so maybe this will help viewers to understand and I'll go over it, and then hopefully, with what I'm telling you and the pictures, it'll make it a little easier to understand. But just keep in mind, it is a super complex disorder. This is why it's so commonly missed as a diagnosis. But there are multiple underlying pathophysiologic mechanisms involved with PCOS. So several theories have been proposed to explain the pathogenesis or the progression of the disease of PCOS. We know that there is an alteration in the gonadotropin-releasing hormone, which results in an increase in LH, and LH is a luteinizing hormone.

And so what we'll say is there's a defect in the pancreas, which releases insulin, and that's due to genetic factors. So because of this genetic defect in the pancreas, we get hyperinsulinemia or elevated insulin levels in the blood. And then there's also insulin resistance that occurs. We have a high level of insulin, and we're resistant to that insulin. Because of the insulin resistance, what happens is blood sugar goes up when blood sugar is up in the bloodstream that triggers more insulin to be released by the pancreas. When insulin gets released, that causes increased sensitivity at the hair follicle, which is why a lot of women will have acne and an increase in facial hair grow, that's one reason. And then it also decreases the production of T3.

Wardee: Thyroid hormone?

Angie: T3 is a thyroid hormone. When we lower that active form of thyroid, T3 is the active form of thyroid. When we lower that, then we're going to have a decreased metabolism, which makes it more difficult to lose weight. And we will experience an increase in visceral body fat. Now, this is different than subcutaneous fat. Subcutaneous fat we can pinch. Visceral body fat is the fat that accumulates inside, it surrounds the organs. That's the dangerous unhealthy fat that can kill us. It's very important to decrease visceral body fat because visceral body fat also increases inflammation. Inflammation contributes to a lot of disease processes. It's like it's a double whammy here. Not only are we resistant to insulin, which makes it more difficult to lose weight, but then we also have slower metabolism because of the lower thyroid hormones.

Wardee: Goodness, it sounds like a perfect storm.

Angie: It is the perfect, perfect storm couldn't have said that better. Also, whenever we have high insulin levels circulating throughout our body, it lowers something called sex hormone-binding globulin. Now sex hormone-binding globulin is great. The higher sex hormone-binding globulin, the lower your risk of mortality in every disease category. Now it's produced by the liver, and so what happens though is whenever we lower sex hormone-binding globulin we will, seeing an increase in free testosterone and free estradiol. When we get a high level of free testosterone, we can be more prone to acne, increase in facial and body hair growth. And then when we have higher free estrogen levels that can increase the risk of endometrial cancer because it's increasing the thickness of the endometrial lining. When you have a high level of estrogen, it causes a buildup of that uterine lining.

If it is allowed to build up and becomes too thick, then that's something called endometrial hyperplasia. And then, if that's not treated or resolved, then that can increase the risk of endometrial cancer. There's a lot of... there's just a negative cascade of events that are happening here that can set the stage for disease. Okay, so there are a few more things that come into play as far as physiology goes. We talked about two other areas where PCOS comes into play. But let's look at another important thing is, with PCOS, we often will have anovulation, meaning you're not ovulating every month or ovulating irregularly, or not ovulating at all, which is why oftentimes, women have difficulty getting pregnant because they're not ovulating.

Well, when you don't ovulate, then you're not producing as much progesterone. When we have a lower amount of progesterone circulating throughout the body, that is going to increase the risk of breast and endometrial cancer. When I said there's less sex hormone-binding globulin, which means there's going to be more estradiol, okay? In order to keep estradiol in check and oppose the estrogen, it's like balancing scales. We have estrogen over here, progesterone over here. We have to have enough progesterone to counteract the negative effects of estrogen. Negative effects of estrogen can be breast tenderness, bloating, irritability, just think PMS type symptoms. If we don't have enough progesterone to counteract that, and that endometrial lining is allowed to just thicken and thicken and thicken then that's what puts us at risk for endometrial cancer.

If we have an adequate amount of progesterone, it prevents that endometrial lining from becoming too thick and then there are no worries, it's okay. We've got another double whammy because we've got high estrogen levels that are building up that uterine lining, not enough progesterone to counteract it. That's another risk. Also, when we have lower progesterone production because progesterone is the calming and mood-stabilizing hormone, it will increase the risk of anxiety and other mood disorders. Very common in women with PCOS to have these types of disorders. Also, when we have lower thyroid levels, that also can contribute to anxiety and depression, and mood disorders. A lot of psychiatrists will use high dose thyroid to treat anxiety and depression. You're looking at two different things that could be causing those mood disorders and anxiety in someone with PCOS. It could be not enough progesterone, it could be not enough thyroid, and it can be both.

Wardee: Wow, wow.

Angie: Then the last area that we look at is adrenal hyperplasia. That occurs in women with PCOS. When we have that happen, we see an increase in your total testosterone, and then also increase in DHEA levels. When we draw blood levels on women with PCOS, we will often see high DHEA levels. And that's another red flag. When we're evaluating women and screening women to try to figure out, do they have PCOS or not, that's something that we always look at. We draw the level, if the DHEA is high, there's a red flag. And then of course, we look at other things too. And then you start seeing all these red flags up here. And then you get enough red flags that you get the PCOS warning and you know, okay, this is probably what's going on. As you can see, there are lots of things to look at and try to put together.

Wardee: And I'm sure some women watching, listening are thinking, "Is that me, is that my daughters?" Talk to us now about the signs and symptoms of PCOS, we can have a better understanding not just of what's happening in the body but what might be visible or symptoms.

Angie: Okay, because PCOS involves both endocrine and metabolic systems and those symptoms influence other symptoms. The signs and symptoms of PCOS vary, and there are a lot of them. A large percentage of women that have PCOS, it's only discovered really that they have PCOS after they have experienced issues with infertility and or miscarriage, and then they go to a fertility specialist, who starts to look in a little more in-depth. And women that are lucky enough to get diagnosed, it's usually because of something like that. Most women I believe, go undiagnosed even though they say one in five, one in four depending on which study you're looking at as we'll see whenever we talk about how it is diagnosed, you'll see how easy it is to be missed. But the infertility is a sign and symptom of PCOS, history of miscarriage, irregular periods, heavy painful periods. Let's see.

It can be difficult losing weight because of insulin resistance and lower thyroid production, elevated insulin levels, hyperlipidemia, or high cholesterol levels. And we see this not only in women that have PCOS that are overweight, what's interesting to me is even the lean women that don't have a weight issue will most likely have high cholesterol levels. Fatty liver diseases common, obesity, high blood pressure, cardiovascular disease. You can have skin symptoms such as acne and the facial and body hair growth that we talked about. Also skin tags, dark velvety patches of skin, sleep apnea. As I mentioned before PCOS patients are at an increased risk of anxiety, depression, and other mood disorders. And because a lot of these other symptoms like facial and body hair growth and excess weight can also cause some psychological distress and have a poor sense of body image. Polycystic ovaries are present in some but not all women with PCOS.

Women with PCOS will often suffer fatigue, thinning hair, dry skin, constipation, temperature dysregulation. It can be either too hot, too cold. The flip FSH LH is another red flag for PCOS. The FSH should be two times higher than your LH, FSH stands for Follicle Stimulating Hormone, LH, Luteinizing Hormone. Family history of breast or endometrial cancer is also common in women with PLCS issues with endometriosis is common in women with PCOS as well, because of the lower progesterone production.

Wardee: Sounds miserable.

Angie: It is not fun. There's some that are mild and there's some that are more [crosstalk]. A lot of women, once they come in, and we talk about things, and they just thought, well, I just thought I had really bad periods, or I thought I had irregular periods, I didn't think it was anything unusual or abnormal. But then when we start seeing other things come into play, it becomes really clear what's going on.

Wardee: Angie, can you tell us how it's diagnosed to be just a little more specific? Because I keep hearing you say things like not all women will have and then you talk about they have so many red flags. So tell us the process of well, maybe from your perspective, how you might diagnose someone and what you're looking for?

Angie: Well, that's the million-dollar question. And really, it is yet to be solved, as far as how we can get more women appropriately diagnosed with PCOS. And I'll tell you a few reasons why. Like you said, there are so many symptoms, and it's the best analogy I have is you're putting pieces of a puzzle together and say a symptom is a piece of the puzzle. Well, if you get enough pieces, on the table and you know that you've had this, you start to get a clear picture that, okay, this is what's going on, it's PCOS. But there's not a clear cut, not one diagnostic test. If you go in and you've fractured your arm, they can take an X-ray and very clearly they see, "Oh well this arm is fractured in this place." PCOS isn't like that. You have to take the time to put all the pieces together. There are some diagnostic tests that can give you more pieces to put together like I mentioned that elevated DHEA levels, hyperlipidemia, high insulin levels in the blood. But there's not even an agreed-upon set of diagnostic criteria that are used to diagnose PCOS.

There's one slide I have here, it's called the prevalence of PCOS. And it depends on the criteria that they use to diagnose it. As you can see here, different medical societies have different diagnostic criteria. Depending on these outdated criteria, women could easily be underdiagnosed, depending on the criteria used to diagnose her with PCOS. When we look at the 1990 criteria that the National Institutes of Health put out, you had to have two things. You had to have hyperandrogenism or high levels of testosterone, DHEA, which is an androgen, and infrequent periods.

Okay, so there are two things and you've heard all those symptoms. And you'll say, well, if we have these two things, then that's the diagnostic criteria. Well, then, in 2003, the Rotterdam criteria came out. And what this was, it was this criterion came out of a consensus workshop that was done in Rotterdam between, it was the American Society for Reproductive Medicine and the European Society for Human Reproduction in embryology. They met in Rotterdam for a consensus workshop and they came up with these criteria. They said you must have high androgens infrequent periods and polycystic ovaries, okay. Then in 2009, the Androgen Excess and PCOS Society put out their own criteria. And they said you must have high androgens, and one of two of the others. Either infrequent periods or polycystic ovaries.

As you can see, it would be very easily depending on which criteria were utilized for a woman to not be diagnosed. According to the Rotterdam criteria, if a woman does not have polycystic ovaries, then she does not have PCOS. However, we know 50% of women with PCOS do not have cysts on their ovaries. And if we use that 1990 criteria established by the National Institutes of Health, they recognize that polycystic ovaries are not required to have PCOS. These two contradict each other there. There are many other signs and symptoms that should be included besides the three listed on the table. But we'll talk a little bit more about that later on. The symptoms of PCOS have actually been documented among women for more than two millennia. Interestingly, Hippocrates, who is a Greek physician, often referred to as the father of medicine documented these PCOS type characteristics in female patients.

And he documented them as having menstruation less than three days of having a masculine appearance, so that could be that facial hair, acne. [inaudible] noted that it is normal for women not to menstruate and that women that do not menustruate tended to be more masculine and robust. So physicians have described a combination of signs throughout time, including menstrual irregularity, masculine body types subfertility, and possible obesity, which could be suggestive of PCOS. But as I mentioned earlier, PCOS is a very complex endocrine disorder, and also metabolic disorder, and it's often missed because of these varying diagnostic criteria.

And for patients, this can be very frustrating because they know that there's a problem, they're going to different doctors trying to get some help, and no one even recognizes it as a problem, so they there, they never get treatment. There is this study that was done in 2011 in Turkey, and it was evaluating the present prevalence, I'm sorry, of PCOS depending on which of those three diagnostic criteria were utilized, and I think it's very telling in regards to how underestimated PCOS is because of the varying diagnostic criteria, which currently exclude the other clinical signs and symptoms of PCOS. In this Turkish study, if they use utilize the National Institute of Health criteria, the percentage of women that had PCOS was 6.1%. Okay, if they use the Rotterdam criteria, the prevalence jumped to 19.9%. And then in the androgen excess and PCOS society using their criteria, it was 15.3. It could have been anywhere depending on which set of criteria was used between, we'll round it off six to 20%. That is a big discrepancy.

Wardee: Maybe you could talk a little bit about what you do in your office, what you look for.

Angie: Okay. When a woman comes into our office, and she is questioning, we know what's going on, because most of the time when women are coming to us, they know there's a problem. Most of the time they've been to multiple physicians seeking help, and they haven't been able to find it. They're looking for answers. So we always do a complete, medical history, we're looking for the menstrual history, like how old were they when they started their menstrual cycle? What types of menstrual cycles do they have? Are they regular? Are they infrequent? Sometimes more frequent. Are they heavy, light? Typically, women with PCOS will have heavier periods. They may go six months, they never have period. And then they may be regular. We're looking at obstetrical history. Have they ever become pregnant? Were they able to carry the baby to term if they had a history of miscarriage? Those types of things.

And then of course, the other symptoms like, do you have a history of facial or body hair growth, acne, difficulty losing weight, some of these anxiety, depression. We're just looking for all those signs and symptoms that we mentioned earlier, and trying to get a good idea of what's going on. Every woman that comes to us we will... if they're pre menopausal, we will screen for PCOS. Once you pass through menopause, it's no longer referred to as PCOS, then those symptoms that are occurring. The insulin resistance, it's just attributed to metabolic disease, metabolic disorder. We're screening every pre menopausal woman for PCOS. We're doing that complete medical history.

We also draw lab work and we're looking for an elevated DHEA level. We're looking for elevated testosterone levels, both free and total, low progesterone levels, lower thyroid, especially T3 levels. We're looking at all of that to get all of the information that we need, so that we can really see clearly what's going on.

Wardee: I love that you're so thorough, and if anybody's wondering at the end, we'll be able to share if you need to get help that Angie and her husband are available. We'll give you steps for that. Angie, now let's talk about how it would be treated. We know what the problem is, a woman has been diagnosed with PCOS, how do you treat it?

Angie: Okay. The severity of the symptoms can be reduced. PCOS cannot be cured because it is genetic, so it's in the genes. We can reduce the symptoms by managing lifestyle factors, such as increased physical activity, proper nutrition, diets that are lower in carbohydrates are better for someone that's insulin resistant. I failed to mention earlier one of the signs and symptoms also, women with PCOS tend to crave carbs more than women that are not insulin resistant. We also focus on stress management, and of course hormone optimization because it is an endocrine disorder. We want to optimize the thyroid and get those levels back in a better range. We want to make sure that you have adequate amount of progesterone. We can use insulin sensitizers such as Metformin to help lower the insulin resistance. We also utilize spironolactone which can help lower your LH. It can help minimize some of the symptoms such as acne and block that conversion of testosterone to DHT which is responsible for some of the acne and hair growth.

The main treatments that we look at is thyroid, progesterone, Metformin, and spironolactone and then the other lifestyle factors. Now sometimes traditional physicians or maybe OB/GYN, they will utilize hormonal contraceptives to try to minimize this symptoms because what it does is it will lower the other hormones that will lower the estrogen, lower the testosterone, and so it can help with acne. And that's fine. People have done that for forever treating PCOS symptoms with hormonal contraceptives. But I don't ever recommend these because these are chemically altered hormones. We're talking about progestins, not progesterone. And so we know, we have tons of literature that show us that these progestins that are in hormonal contraceptives, they can cause or increase the risk of breast cancer.

So we have a population of women, women with PCOS, they are at risk for breast cancer anyway. They have a higher than normal risk of breast cancer because of that lower progesterone. Progesterone destroys breast cancer cells, it protects against it. There are some studies showing that progesterone is as effective in treating or preventing breast cancer as tamoxifen, which is one of the drugs of choice to treat breast cancer. If we know we have a group of women that are at high risk for breast cancer anyway, why in the world, give them a synthetic hormone that we know has been shown to increase the risk of breast cancer. We're just putting them at more risk, so I would not recommend it. There are some, physicians that do that and it does help manage some of those symptoms.

Wardee: When you say contraceptives, you're talking about conventional birth control pills, right?

Angie: Yeah.

Wardee: And you and I talked at length about the dangers of synthetic hormones in our previous podcast at wardee.com/hormonepodcast, all one word. So if anybody wants to know more about what Angie just referred to, you can go there. It's a scary thing, to go down that route instead of the bio-identicals, which is what Angie is now saying is the better approach, real progesterone, not progestins.

Angie: Right. The progesterone that our body once made on its own, it's just as we age, that production declines. And in women with PCOS, they just don't make enough of it anyway. If we can ever replicate what nature gave us in the first place, we're always going to get a better result with fewer side effects. The chemical structure of the hormone that I'm talking about bio-identical progesterone, it is made in a compounding pharmacy but once it has gone through that compounding process, the end product, the chemical structure of bio-identical progesterone is identical to what your body wants made. Of course, we're going to get a better result from the exact chemical that we made, as opposed to something that's chemically altered and foreign to the body.

Wardee: Yes, makes a ton of sense. Do you want to talk a little bit about what happens if PCOS is not diagnosed and treated?

Angie: Sure. This is, I think, the most compelling thing that I could say for people to get screened and to take action. I've heard women come in and say, "Well, I went through the fertility treatments, and I was on Metformin before, they put me on it. But since now I'm not trying to get pregnant, I didn't think that I needed it. So I haven't been taking Metformin." PCOS needs to be managed no matter what, if someone is trying to get pregnant or not, no matter what the circumstance, if you have this genetic disorder, it needs to be managed indefinitely, because if it is not managed, it can have devastating long term health consequences. And this is why I'm so passionate about this disorder. And one of the reasons why I want to educate women, and the people that I love them, about PCOS.

If PCOS isn't managed early on, it will lead to type two diabetes, heart disease, obesity, increase their risk of breast cancer and endometrial cancer, and all of the complications that go along with those disorders, not to mention the mental health aspect. A lesser body image, anxiety, depression. For quality of life reasons, and to prevent those very devastating diseases, if you think about type two diabetes alone. I watched my grandmother suffer with type two diabetes. She lost her vision because of the poor circulation. She had all this neuropathy pain in her lower extremities and poor circulation.

It had a devastating effect as far as hypertension, cardiovascular disease, kidney disease. Diabetes affects every system in the body. If we can prevent that, by managing this early and spare someone that suffering, why would we not do that?

Wardee: Yes, I agree. Now, I would like to ask a question just about the insulin resistance management because you're talking about using Metformin. I would say our audience is somewhat opposed to pharmaceuticals in favor of bio-identicals. Could you just address a little bit the safety issue with Metformin and if there's other non pharmaceutical options to managing insulin resistance?

Angie: Yes. Things that we can do to lower insulin resistant naturally are to increase activity, adequate amount of exercise, that lowers insulin resistance. Having a good healthy diet, no processed foods, real food, lower carbs, that's going to help also lower insulin resistance. When we optimize the thyroid, that is going to help lower insulin resistance. There's two studies that I would encourage anyone that's interested or concerned about this topic. And considering what should I do with Metformin, no Metformin. There's two studies, one of them is called the Tame T-A-M, as in Mary, E, Tame. And the other one is this, Miles, M-I-L-E-S. The Tame trial and the Mile study. If you look those, Google them, you'll find all kinds of stuff that comes up about those.

And those were studies that were done on the use of Metformin by anti aging academies, because of the positive health benefits that it has. And also the benefit as far as anti aging goes. Now, we don't really like the term anti aging, because there is no true anti aging as long as you are breathing and days passing. Then we are going to age, but the goal is to try to age as strong and as healthy, and preserve the best quality of health for as long a period of time as we can. Metformin has been around for a long, long time. And I've been taking it every day for the last probably 15 years.

We do have to be careful and if we have someone that is a, heavy drinker, it can cause some problems so we have to caution patients and make sure that that's not the case, because it can cause problems in patients such as that. The most common side effect of Metformin can be stomach upset, gas, bloating, diarrhea. So we always introduce it very slow, take it with meals to avoid those types of effects. But the long term risk of not managing insulin resistance is far greater than any risk that Metformin, might provide or present.

Wardee: I see. Would you say that there are viable alternatives to Metformin that somebody could manage insulin resistance without it? Or would you say, it's necessary most of the time, from your medical opinion?

Angie: For me, I take it. From my perspective, it needs to be managed, and it's a very useful tool that we have. You can try to manage things by just doing thyroid. I feel that our job is to provide patients with as much solid evidence based information so that they can make an informed decision for themselves. That's patient rights, you have the right to make decisions about your health care. And our job is to give you tools so that you can make good decisions. Whatever decision you make, that's up to us to support you. Now, there's some things that we obviously would say no, if it was going to put you at risk, like we would never give a postmenopausal woman, estradiol without an adequate amount of progesterone to counteract that, because that would just be reckless, we wouldn't do it. But, as far as someone taking Metformin, not taking Metformin, that's up to them. We'll give them the information. They make the decision about it. I've chosen to take it for myself.

Wardee: Sure. Great. Well, I appreciate you indulging me on that question. I want to make sure that everyone has information. And I know there's pharmaceuticals that have been around for a long time that have more benefit than risk and having the information like you said, so a person can make informed choices about their health care is the best way and I love that you and your husband support that.

Angie: Sure.

Wardee: And I love the work you're doing.

Angie: Thank you. We love the work that we're doing. There's another thing that should be said is, when patients go online to try to find information, we try to steer them towards really reputable sites. And we provide a lot of patients with a lot of studies that we have libraries for patients that they can look at. We're filming a video library so that they have access to a lot of information because we have a collection of so many different studies on all kinds of things related to hormones that it would be very difficult for a regular person to decipher what that means. Because some of these studies, you have to really look at, okay, well, the outcome of that study, what does it really mean? The meaning of the study can be skewed depending on the methodology or the way that the study was designed.

I could design a study that would show you morphine is ineffective at treating acute pain. Okay, we know that's all not true. We know morphine is very effective at treating pain. But if we designed a study, so that we only gave one milligram of morphine to someone in acute pain.

Wardee: Extreme pain.

Angie: Yeah, terrible, worst pain you've ever felt, and we give you one milligram, it's not really going to do much to relieve your pain. But if we give 10 milligrams of morphine, then that's going to do a pretty good job of managing that pain. A lot of times, if someone doesn't really take the time to study the studies that are there, it can make things appear totally different than they really are. Does that make sense?

Wardee: Oh, yeah. That's a great, great point.

Angie: Yeah, we need to be-

Wardee: Yeah, that's why we have to be careful with studies and headlines, because there's headlines saying, avoid all hormones, they cause cancer. Well, it's not true for bio-identicals in the proper balance, and managed with optimal levels, et cetera. Yeah, I totally agree. I'm glad you pointed that out. And I'm glad that you and your husband are doing work to sort through that for your patients, and even the larger audience that we're reaching through this podcast and through the work that you do, so yes. Great. All right.

Angie: Well, thank you. That's why we started the Center for Research that we have here and hire Dr. Scott Howell, who is a researcher. He's done research with the National Institutes of Health and in other organizations, because we want it to be able to offer patients access to someone at that level of knowledge to be able to help us decipher through some of that and then also provide education for patients. He does a lot of podcast too, keep those as well, you can find those on YouTube and on our YouTube channels, too. But it's important to really understand because things aren't always as they appear, just like you mentioned, and we talked about that on the last podcast when we were talking about the Women's Health Initiative and what was put out. That hormones cause cancer, oh, my gosh, everybody should be off hormones.
Well that study was only done using synthetic hormones. And yes, I would agree with don't use synthetic hormones, those can increase your risk of cancer, especially when you're combining two synthetics together, not the same, as you said with the bio-identicals. We just want to make sure that we provide patients with solid evidence for their decisions.

How To Work With Angie (Virtual Options)

Wardee: Yes. So I think now's the perfect time for us to wrap up with how you and your clinic work because people all over the country can see you or get more information from you. Everyone, I'm going to include a link to Angie's clinic Tier 1 Health and Wellness with this video, or if you're listening with this audio, so make sure to check that out. And now I'll just turn it over to Angie to talk a little bit about how our practice works and how if you're interested, you might work with them.

Angie: Okay, so prior to COVID patients would have to make a trip to Tennessee, we would have to see them in person one time for them to become established as a patient. When COVID hit, they wanted people to have access across state lines and make healthcare more accessible to more people. Those requirements have been loosened. And so now we can do everything via telemedicine from the beginning. Patients can become established as a patient through telemedicine. We have contracted rates for labs through Quest and LabCorp. Patients can go to either a Quest or LabCorp facility near where they live. And there's usually a Quest or LabCorp within a reasonable distance from anybody's home in the US.

Then we work remote with them through telemedicine, phone calls, we have HIPAA compliant patient portals, patients can send us messages and ask questions. It's unlimited access. If anybody's interested, all you have to do is either give us a call or go visit our website, and you can send in an inquiry through our website, which is www.tier1hw.com. And we'll be happy to help you. I do free consultations every day, 30 minute consultations to answer questions that patients may have to see, if we think what's going on may benefit from hormone therapy and explain the program, how it works and how we follow up with patients and things like that. Any questions you have, I'll be happy to answer them for you.

Wardee: Great, so everyone, in case you didn't catch that I will include the information with this video so you can get in touch with Angie. Even if you don't though, this information is so wonderful that our goal is really to inform you just like Angie. My goal is to inform you mine and my husband's. And just like Angie and her husband, with their practice want to give the best information. This should empower you even with your current doctor, searching for a new doctor because the more information you have the more educated you are going into those appointments. The more you can be proactive in your own health care, deciding against somebody, asking for specific testing, I would like to look into this, I'd like to know this. What do you know about this? You need to know this information.

And I'll tell you from my perspective, I talked to a lot of women too. And I talked to them for skin and hair care and some wellness topics, but I'm not a doctor or a nurse. And when I ask people have you talked to your doctor about this? Or have you got tested on this? A lot of people don't even know what the... they don't know what their thyroid levels are. They don't know, and it's very sad. I would encourage all of you who are listening to just get more involved in your health care. And anytime you have blood tests, ask the doctor or the nurse practitioner? What are you testing? And can I have a copy of it? You should have your own file with your own records, that you can be proactive. And then you're listening to a podcast and somebody tells you a number like in our hormone podcast with Angie, she gave us levels, optimal levels of different hormones.

If you have your own hormone test, you can see, well, how am I doing? Anyway, that was a little side tangent, but I just feel like it's so important to empower people to be in charge of your health, know your health and be educated.

Angie: That is excellent advice, Wardee. I tell people all the time, you have to be your own best advocate and educate yourself about whatever it is, whatever health topic it is. Because I hear because I talk to people so often, I hear so many stories of patients that their symptoms were just dismissed, or they've never given a thorough explanation about, like you said, what their lab results are what it means. And it's important to know that when labs are done, what that normal reference range out there represents is an average of everyone that gets tested. That doesn't mean that's what your body needs to feel and function its best. And depending on many factors, genetic makeup, chemicals you may be exposed to in your environment, stress levels, all these various things, receptor sensitivity, what you need and what I need, and the person next door needs, it's going to vary.

You need to understand what your level is. But just because that level may fall in a, "normal range" if you are symptomatic for things, most women when they come to me, they know there's a problem. But they've been dismissed, and they're looking for that answer. Thankfully, they're persistent and they keep pushing. But for everyone, I feel like it comes and finds their way to somebody that will sit and listen and try to help them. There are so many that when they hear, "Your levels are normal, it can't be." They just accept it as, "Oh, okay, well, I guess it can't be that." They're the doctor they know. And then they settle for or suffer through a lesser quality of life. And that's the saddest thing is because they don't have to, I hear these stories, day in and day out. That's really what drives us.

Even if you don't come see us, I said these the last time, I always say this, go see somebody that's knowledgeable that will listen to you and that will help you and that will be a partner and an advocate for you. That's what a provider should be.

Story: "Thank You For Giving Me My Wife Back"

Wardee: Yeah. And so the last thing I'd like to do, Angie, before we say goodbye, is if you could share one of those stories that you shared with me. And I'll just preface this by saying, in the hormone podcasts that Angie and I did wardee.com/hormonepodcast, all one word. Lots of women have listened, many of them have reached out to Angie. Over the past year, Angie has been working with several. I don't know who they are, or how many. But if you could just share a story that, without names or whatever, that could be an encouragement to other women who are suffering to give them hope?

Angie: Well, I'd be happy to. The most profound example that I could give you was the one that I shared with Wardee. And this is, again, what motivates us to do what we do and why we want to get that word out there. Because there was a woman who was listening to your podcast Wardee, and she was feeling like... and it gives me chills when I even say this and think about what she told me the other day. When she came to us, she was very depressed. She felt as if she was not able to give her family what they deserved. She said that she was not a happy person, that she had no interest in many of the things that she used to enjoy. She had zero interest in... she had zero sex drive and no interest in her husband at all. So severe that she had even told him that if he wanted to basically have a girlfriend, that she would be okay with that because that was how little interest she had in him.

And she said she felt her children deserve more, her husband deserve more, but she was unable to give it. And she heard the podcast and she called, which to me is amazing that she was at that low of a point. But she still reached out because that takes a lot of courage, really. She reached out, we did a consult, we got blood work done, got her started on hormones. It was very clear she was postmenopausal. When you're dealing with post menopause, pretty much every hormone is going to be at zero, so you have nowhere to go but up. So we know that there's going to be a positive result. And a month later, she was doing a lot better, less depressed, all that. But in three months later, totally different person. I did not hear the despair that I had heard from her the first time.

She was actually interested in a sexual relationship with her husband. She said he was thrilled, could not believe the change that he had his wife back. She said, even said, tell you thank you that you've given him his wife back. It just totally changed not only how she felt and functioned, but her entire family. And to me that's the greatest thing that we can do.

Wardee: Absolutely. I have the chills too. And I when you told me that two weeks ago, I printed it and I ran upstairs to my husband. I said, "I know you're doing your Bible study right now, but I have got to read you this." It's just so beautiful, so beautiful. She felt like she had no hope but she still had a little bit of hope because she listened and reached out.

Angie: And reached out. Yeah.

Wardee: She knew it was not lost. That there was a possibility. But you gave her that hope, Angie. I'm so grateful to you.

Angie: You got the message to her. You got the message to her. She was listening to you. You're doing great work I appreciate you, being concerned about these women's issues and putting things out there for women. Because there is so little avenues for women to go to get information like, you can go on a lot of these YouTube channels, I wasn't aware of this until we started doing some of this ourselves. But there are tons of forums and YouTube channels where they're talking about male hormones, man and testosterone and all of this stuff. And it's easy to find one. But when you start looking for female podcasts on female hormones, it's really hard to find solid information.

I've started trying to find some just to listen and see what people are hearing, and there's some scary information that is being put out there. We want people to know and understand, there is hope, there is help, things can change. We don't have to settle for lesser quality of life and there are people out there that can help. Anyway.

Wardee: Amen. Well, thank you so much for your time today, Angie.

Angie: Thank you.

Wardee: Thank you everybody for listening. Be sure to reach out to Angie if you'd like more information. If you're watching or listening to this, and you want to read or share this with anyone, there is a complete transcript below or linked. If that's an easier way for you to share or save or digest the information, be sure to take advantage of that as well. And I will just wrap up by saying thank you for being with us. Thank you, Angie. And God bless you all.

Angie: Thank you. Thanks, Wardee.

Wardee: Bye-bye.