“Giving bioidentical hormones in the right dose can attenuate against weight gain. I’m not saying that it’s a magic bullet, that if you take the hormones, you don’t have to do anything. But I am saying that if you take hormones, you may just find that your metabolism starts working again.” – Dr. Anu Arasu
“It’s the whole lifestyle. It is not just estrogen and progesterone and testosterone. It is cortisol and insulin and all the rest of it.” – Dr. Anu Arasu
Has your doctor spoken with you about taking progesterone? Are you entering menopause and considering natural hormone replacement therapy? Dr. Anu Arasu specializes in treating a variety of hormonal imbalances with bioidentical hormones and a holistic, functional medicine approach. Listen in (or read the transcript) as we discuss her approach to hormonal replacement therapy for women with PCOS and much more.
- Connection between inflammation, weight gain, and hormones
- Suggested tests to get to the root of your hormonal imbalance
- Provera vs. non-synthetic option
- The role of cortisol (especially in lean PCOS)
- When to sleep
Mentioned in this podcast:
- London Bioidentical Hormones
- Podcasts with Dr. Poppy Daniels:
- DUTCH test
- Podcasts with Dr. Izabella Wentz:
Amy: So, today we’re going to be talking about a subject that I know a lot of PCOS Divas are interested in. And that’s natural hormone replacement therapy. And I’ve reached out to one of the experts in this subject, and it’s Dr. Anu Arasu. She is one of the first doctors in the U.K. to train in functional medicine, and she specializes in tailor-made hormone therapy at her clinic, London Bioidentical Hormones based on Harley Street in London. So, so glad to have you here, Dr. Arasu.
Dr. Arasu: Thank you very much, and thanks for that introduction, Amy. It’s great to be here.
Amy: So, I love the miracle of technology that we can be talking across the pond.
Dr. Arasu: I’m sure you’ve got a nicer, a bit of a nicer view than I do right now, 3:00 P.M. on a rainy London day, but yeah.
Amy: Oh gosh, I don’t know about that. It’s kind of dreary here in New Hampshire. Hoping for a nice warm 74-degree day tomorrow, so I can start doing some gardening. I’m really looking forward to that, but. So yeah, let’s kind of just jump right in. I’ve done some other podcasts about natural hormone replacement therapy, especially progesterone, and if people want to get more information, definitely listen to my podcast with Dr. Poppy Daniels. But I really wanted to touch upon natural hormone replacement therapy again, because it’s something that I think women are hearing more about it and how it could possibly help with PCOS. Maybe you could just first sort of talk a little bit about the hormonal imbalances of PCOS and how natural hormone replacement therapy could possibly play a therapeutic role?
Dr. Arasu: Yeah, no problem. So, PCOS is essentially a hormone imbalance. What is PCOS? It’s defined by three things, really. Number one, someone has few or no periods. Number two, they tend to have high male hormones like testosterone. And either these are high levels in the blood or possibly they’re normal levels in the blood, but they have the clinical symptoms of high male hormone levels. So, for example, they might be finding they’re getting hair on the face, hair on the shoulders. They may have kind of that coarse thicker terminal hair, the type you only find on eyebrows, and they have that in different places such as the face. And the third part of the diagnosis is if someone has multiple cysts on their ovaries on an ultrasound scan.
So yeah, the question is why would this pattern occur? And actually what we know is that when there are hormone imbalances such as insulin resistance, it can affect the LH surge which can interfere with ovulation and it can actually push the male hormones, like testosterone, up high. So essentially, PCOS is a bit of a hormonal storm. And that’s why I think testing and trying to rebalance the hormones with bioidentical hormones can be a really great approach.
Amy: So, just curious, what type of testing do you like to do for hormones? Do you do something like a DUTCH test?
Dr. Arasu: Yeah, I really like the DUTCH. So, serum and urine testing is great. I think urine testing has the added advantage of looking at how one metabolizes the hormones, so you can actually see, for example, if somebody has a normal testosterone, but there’s something identified about the pathway, they’re more likely to get side effects of acne or hair growth. So, that kind of thing can be useful which you get on a urine test. I mean, the DUTCH test also looks at cortisol. And I think this is very relevant particularly for our slimmer PCOS type patients because, in their case, what is the drive if it’s not diet? Actually, are there high stress levels? Other conditions can be driving insulin resistance even in them.
So, the DUTCH test is great for all of those things. It also has markers of oxidative stress on it, which again, I think is relevant to PCOS and so much of some of the problems are inflammatory in nature. Serum levels are fine and you can also do genetic testing on them. You can also get similar information from a serum test plus a gene test to look at the genes that control how you handle estrogen. So, these are the kind of tests I do. I mean, one good thing about serum tests is that, for example, if you want to know if you’re ovulating or not, that day 21 progesterone is recognized by lots of doctors, even those who aren’t in the functional medicine trade. So, seeing that day 21 progesterone is typically low, yeah, people are going to take note. So that’s the best way, I’d say. It kind of depends on the case, but…
Amy: Well, and for those listening that aren’t familiar with the DUTCH, I did a podcast on that and I’ll put that in the show notes as well. I think a lot of women have heard or even have like compounding pharmacies that sell these natural hormones over-the-counter, and I hesitate for people to just start using them without having some baseline labs to sort of see where they’re at and to work with a doctor like yourself on a plan.
Dr. Arasu: Oh, completely. I wouldn’t, personally, take anything without the test. I really wouldn’t. I think it’s subtle. The human body is subtle. I think testing can be incredibly useful and you always get surprised. Sometimes your result will come as one way and we may think we’re not stressed, for example. We may think that stress is not a problem for me and then you get back a 24-hour cortisol level, well it could be a surprise. The 24-hour cortisol is okay, but you’re not clearing it out. It’s hanging around in the system and then when it is being broken down, it’s being broken down into stimulating metabolites. So, it’s interesting to have that extra information and I think if you’re going to start something like progesterone cream, you’re potentially going to be on it for a while. You want to know what kind of dose to start, what your insulin is doing, when things are getting better when you may not need so much.
Because, one thing about hormones. I always think of them like circles. Too much can sometimes give very similar symptoms to too little, so it’s quite interesting. There really are symptoms of too much, as well, and we must look out for that.
Amy: Maybe you could … I talk a lot about how there is no one-size-fits-all approach to women with PCOS, you know, we’re all different. But, maybe just for the sake of this podcast, what would your classic woman with PCOS, whose come to you with typical lab results? What would your recommendation for hormonal replacement therapy kind of look like for her?
Dr. Arasu: Yeah, so often first of all they come in and I’d say probably the majority, maybe 60-70%, are struggling with weight. That’s another part of it that’s making them unhappy and in that picture, what we’ll often find on the hormone blood tests is high estrogens, high testosterones, lower progesterones, possibly DHA normal or high. Thyroid antibodies, I think, are really useful to do because there is a big link between thyroid antibodies and polycystic ovarian syndrome. And, in that case, you really want to be working on addressing the root causes and balancing out the hormones.
So, when I say “addressing the root cause,” I think this is a lot of what you do, Amy, but working first of all on the if the testosterone is high, the driver behind that, which is often insulin resistance. I do tend to test insulin resistance, as well, so you can actually might get an idea of the SHBG or you can actually do a fasting insulin test or even a fasting insulin tolerance test, where people have a blood test done and then have a glucose and have it repeated after two hours and then you can really pick up quite subtle levels of insulin resistance just beginning. Hence, the plan would be really working on diet and lifestyle changes to address that insulin resistance and, yes, often looking at supplements that could help clear out estrogen. Certainly, if they’re not having many periods, correcting that low progesterone is key. At any rate, it’s always important, but especially if they’re not having many periods.
Amy: I love that you said “getting to the root cause,” and I think that there’s this idea sometimes that there’s a magic pill and even progesterone cream is sort of the magic pill and you can’t use supplements to kind of fix up a crappy diet and no exercise and being stressed out all the time. It just doesn’t work that way. I mean, working in conjunction with each other.
Dr. Arasu: Oh, none they’re found anyway, no. No, absolutely not, no. That’s the thing. These things don’t happen overnight. They’re tendencies that have been forming for a while and correcting them is going to change the rest of your life, really. It’s going to change many other things, but it’s not just the EH and progesterone balance that we’re worried about. It’s the fact that this predisposition to diabetes or the increased incidence of thyroid antibodies and what does that mean for other inflammatory and autoimmune conditions, so it’s really you want to be investigating the root cause because it is wider than just this one diagnosis.
Amy: You mentioned about this classic PCOS patient that is getting irregular cycles and may not have had a cycle in months or even years. What do you do in that case? I know a lot of conventional medicine doctors will give their patients a prescription for Provera. What do you think. Yeah, go ahead.
Dr. Arasu: Sorry, what was the last part that you were saying?
Amy: Well, I was just going to day, what do you think about that recommendation to give your patient a prescription for Provera to induce a period, if she hasn’t had one in a while and what would you do?
Dr. Arasu: Yeah. So, first of all, I’m not a fan of Provera. Provera is medroxyprogesterone acetate, so it is a synthetic progestin. However, so basically I can think of better alternatives. However, the logic of what they are doing is to try to get something to thin the lining of the womb is what needs to happen. There are just many, many better things that they could use. So, one of the issues about being in a high estrogen state like progesterone, if you’re not having a period, what is happening to that lining of the womb that’s been built up by estrogen, that is not being shed out or isn’t removed by the body, which normally progesterone would do, what is happening?
We do know that people with polycystic ovarian syndrome can be at increased risk of endometrial cancer because of this issue, because of not having very many bleeds. And it is for this reason, if someone is having less than four periods a year and they actually do have really high estrogens, they absolutely need to take something. I would be very strongly for the idea that they take bioidentical progesterone in order to use a bleed and to thin the lining of the womb.
Amy: So, in what form would that be?
Dr. Arasu: It really depends on the patient. I do use creams, lozenges and also capsules in some, so it does depend on the patient. Again, individual variation is quite wide. Some people tolerate progesterone really well. I mean, I think a lot of people tolerate it well. You’ll always get some people who don’t tolerate progesterone so you have to find what’s right for that person. You have to work out why they may not be tolerating it. Are they converting it to cortisol? What’s going on?
Amy: Can you tell us a little bit about the role progesterone plays in early pregnancy and why women with PCOS might be kind of compromised, I guess. If we’re already low on progesterone, is there something that we should be aware of when we do get pregnant?
Dr. Arasu: Yeah, so it’s interesting because women with PCOS often have very good egg quality in reserve. One of the issues is about the fact that they’re not ovulating. This makes it very hard to time when to have sex and to know that this is why you’re having a problem. You say we’re trying for a while and nothing’s happening. But, actually, the eggs generally are good quality, good reserve. Progesterone in pregnancy is that progesterone is pro gestation, is the hormone of pregnancy, and is the major player in the first 12 weeks, the first trimester of pregnancy. Yes, it is. It has an impact on our T-helper cells and these are involved in maintaining pregnancy.
Look, I think if somebody has a luteal phase progesterone defect, i.e., is having cycles and often that progesterone is low in the second half of the cycle, doctors, if they pick it up, will often give that person progesterone. And what tends to be the bend here. I don’t know how it is where you are, but clearly everyone who’s on IVF will have progesterone. Often women who get pregnant later on, say 40 and above will be given progesterone for the first 12 weeks.
Again that’s not a fixed thing but that’s often the case . You know, one can even test progesterone in the first trimester and actually look at the reference ranges in the first trimester. If low, on the low side, I think it could be very useful. Evidence is, I’m not sure I think we have enough evidence to say that conclusively but certainly anecdotally, a lot of people find progesterone in the first trimester very helpful for preventing miscarriage.
They seem to have had miscarriages before. When they took progesterone, who knows what is the thing that helps. How can we prove it?
Dr. Arasu: But yes, it’s not an uncommon thing to hear.
Amy: You were talking about cortisol and especially for thin women with PCOS, cortisol can be an issue and that’s certainly been my experience. I’m just curious. What do you recommend for your patients that have more elevated cortisol or you know, even like inverse cortisol rhythms. What do you recommend?
Dr. Arasu: It does depend on the course of that person. I think if really they’ve got something, some big obvious emotional elephant in the room, that’s… or if it’s not obvious to them but there is something emotional that needs to have been dealt with, that’s key.
I think from a physical perspective, sleep is the big one. Sleep and stable blood sugars, but sleep is the one that is so involved with our circadian rhythms. So just with sleeping at the wrong time. I mean, I have a lot of patients who at least go to bed very late. You know, they’ll go to bed in the early hours of the morning every night. And then, they will wake up very late.
Actually, it’s not helpful for them from the insulin resistance point of view. We might think, oh I was just born that way, but no probably not. Probably there are things that we could do to normalize it. Night shift workers, classic problem. We know that night shift workers have a greater insulin resistance. Even type two diabetes. Metabolic syndrome. Just by working night shift. Even if they get the same number of hours of sleep during the day.
It’s not that they’re not getting enough sleep. Of course if somebody is stressed. The first signs of HP axis dysfunction that cortisol may be going up in the evening. You may have problems falling asleep. Or they may fall asleep and then wake in the early hours with a bit of an adrenaline surge. So, yes. I would be quite on board with improving sleep.
Dr. Arasu: Yeah. Do you find the same thing? How do you approach it?
Amy: Oh gosh. Yeah, sleep I think is so underrated, and I think women with PCOS tends to be night owls for some reason. I don’t know why we like staying up late and it’s hard for us to get up in the morning. So yeah, I think that’s made a big difference in my life.
Dr. Arasu: How did you manage to then force yourself to go to sleep earlier?
Amy: I think I call it sleep hygiene. Just not watching TV until I go to bed, so I can give my brain a chance to unwind. Taking hot baths with Epsom salts to… that magnesium is really relaxing.
Dr. Arasu: Yeah.
Amy: Reading. Just reading like, you know, not a super stimulating book beforehand. Blue light blocking glasses have helped a lot as well.
Dr. Arasu: Mm yes. I mean, this is why this is such a big problem nowadays. Of course, circadian rhythms. Now melatonin’s made in the pineal gland. And the pineal gland is essentially our connection to nature. It responds to moonlight. It responds to sunlight. So, when not waking up and getting two hours of natural light. Which let’s face it. Most of us aren’t. I mean, even 20 minutes, it’s you know, you’re not waking up to natural sunlight. And then, we’re coming into artificial on the computer screen.
Circadian rhythms really suffer. Yeah.
Amy: I wanna shift to women with PCOS and perimenopause, menopause. I’m there. I’m 47, gonna be 48 this year. So, I’m kind of entering this stage of my life, and I know my mother was like in her early 40s when she had a hysterectomy and was on Premarin for quite a long time. Which is problematic now, but when you see women going in perimenopause and menopause with PCOS, are there hormone replacement therapies that are right for us?
Dr. Arasu: I think the beauty about bioidentical hormones, which is what I’m describing is that everybody you would test and just give them what they need. So, as where another one who may need testosterone in perimenopause. Someone with PCOS may well not. So, in that sense, you’d only end up giving them what they need.
I think some women find that with the menopause, they actually feel that they get a bit more face…hair on the face. A bit more androgenic symptoms and they say, why is this? It’s ridiculous. It’s embarrassing. I’ve got acne. It’s because estrogen and progesterone dropped off at menopause. The testosterone will still be around, could still be around.
And then, one could make one’s own endogenous levels more prominent. One’s own endogenous testosterone levels more prominent if they are not abnormally high. So, I think this could be an issue for some women with PCOS.
But I have to say, a lot of patients with PCOS, their hormone imbalances can correct themselves before this time. You know, if they do the work, really the hormone imbalances correct themselves. So often, your testosterones come down and if it’s not such a big issue. Testosterone might be in its late 20s or…
Amy: I hear you saying again, like, doing the work is so important.
Dr. Arasu: Yeah, yeah. When we talk about doing the work, I mean in perimenopause and menopause, these are anyway a state of inflammation and oxidated stress.
Amy: Mm-hmm (affirmative).
Dr. Arasu: So, with the best one in the world, as soon as we enter perimenopause and menopause, we are entering a state of inflammation, increasing insulin resistance, so perhaps if you already have a predisposition, a tendency to insulin resistance, you have to work a bit harder this time of your life not to put on weight.
Dr. Arasu: That’s another thing I think PCOS sufferers might find challenging about this time of life.
Amy: So because insulin resistance naturally increases anyway for women at this stage.
Dr. Arasu: At this time.
Dr. Arasu: But you know, given back the woman who is very preventative so in fact, we’ve done studies and that when insulin drops to menopause levels, so it’s pretty undetectable. That flicks on an ALDH-181 that can make us put on weight centrally. So, actually giving back hormones in the right balance has to be the right dose. And giving back bioidentical as opposed to synthetic ones that may bind to other receptors.
Giving back bioidentical hormones in the right dose can attenuate against weight gain. So not saying that it’s a magic bullet, that if you take the hormones, you don’t have to do anything. But it is saying that if you take hormones, you may just find that your metabolism starts working again.
Amy: Mm-hmm (affirmative). You can put those hormones back in that perfect ratio. Well maybe not perfect but in a better ratio.
Dr. Arasu: Yeah exactly.
Amy: Do you have other tips for women with PCOS? Women that you see in your practice. What are you recommending for them in terms of, you know, lifestyle?
Dr. Arasu: Yeah. So, I would be saying three meals a day, no snacks in between. I would be saying low GI. So, focusing more on protein, vegetables, moderate to lower carbs. Try to drink plenty of water. That’s gonna be helpful for the detox perspective. Even just to clear out their own estrogen levels.
Avoid constipation. Constipation can cause the recirculation of partially metabolized estrogen. If they have thyroid antibodies, I would dig a bit deeper, think about something in the gut. So, this is the link between inflammation in the guts and it’s that predisposition to the formation of auto antibodies.
Amy: For those that don’t know what thyroid antibodies are, can you explain that?
Dr. Arasu: Yeah. So, thyroid antibodies are when we begin to form an immune response against our own thyroid. So, our antibodies are beginning to attack its own thyroid. And why would that happen? I don’t know. A few theories.
One of which takes into the function in the world is try to see if the gut is the insane way that we would communicate with the outside world. We’ve got lining that’s supposed to… like I said, it’s supposed to let small molecules in, large molecules out. If it becomes leaky, it lets large molecules out and a response against those, and in doing so can begin to even attack our own bodies.
Certainly, things like giving up gluten thyroid antibodies. Isabella Wentz has got a great book on everything you could possibly do to lower your thyroid antibodies. Yes, so I think it’s a useful thing to pick up because number one, if you leave it, the thyroid could become a bit slow. Hashimoto’s.
Number two, even if it’s not yet at the stage where it’s affecting your thyroid, it’s a sign that there’s an inflammatory process going on. It’s a sign that already you should really be looking at the diet, and the gut, and thinking what is going on.
Amy: Those risks for thyroid issues, they kind of reappear when we’re entering menopause too. Isn’t that correct? So, we have to stay on top of it.
Dr. Arasu: Women with PCOS are four times more likely to have Hashimoto’s. Look, we’ve still got to keep this in perspective. I know, sometimes it sounds very worrying. Still keep it in perspective. There are plenty of people that don’t. But yes, definitely check. Definitely check. It’s a useful test to do. Often overlooked.
Amy: For those that are listening that aren’t in the UK, do you have any advice on trying to find a practitioner that does what you do here in the States?
Dr. Arasu: I’m sure a bioidentical hormone doctor in the States would address this as well. I think it has to be somebody…I would go with a bioidentical hormone doctor with an interest in functional medicine because especially…PCOS as we said, it’s the whole lifestyle. It is not just estrogen and progesterone and testosterone. It is cortisol and insulin and all the rest of it.
But I think you have quite a bit of bioidentical doctors in the States, don’t you? I’m able to go to a number of vectors and various things, so yeah. I think you should find a bioidentical hormone doctor with a functional medicine approach.
Amy: Yeah and I do think that that’s so key is that functional medicine, you know, integrative approach…
Dr. Arasu: Yeah.
Amy: To the root cause which I heard you say several times in our interview today.
Dr. Arasu: Yes, yes. Definitely.
Amy: Well, I so appreciate you coming on and sharing your knowledge with us. For those listening that are in London and the UK, tell us how they can work with you.
Dr. Arasu: Fine. So, I am based in Harley Street. The website is a good place to start. It’s www dot londonbioidenticalhormones dot com. I think generally, if you’re not sure if you have a hormone imbalance or this is the right route, drop us an email. And we would see if it’s the right approach but certainly if it’s something that we can help with, then we normally have a questionnaire, a very extensive questionnaire and that’s the way, we’re going to go through everything and really try to rebalance the hormones.
Dr. Arasu: Very much looking at diet, lifestyle, nutrition, supplements, and bioidentical hormones.
Amy: Yeah and I just wanted to give a shoutout to your social media. You have a great Facebook page and you post all your blog articles which are really informative. Definitely give Dr. Dr. Arasu a follow on Facebook and Twitter and we’ll put those social tags on our…in our show notes for you.
Dr. Arasu: Great, perfect. It’s been really great talking to you.
Amy: Yeah, it’s great to have you. Thank you so much and thank you everyone for listening. I look forward to being with you again very soon. Bye-bye.